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Based on observations made on May 21, 2013, the facility failed to maintain the fire and smoke resistance rating of a wall assembly in a building of Type V (111) construction. The deficiency could affect a very limited amount of residents, staff, and visitors in two of seven smoke compartments.

The findings include:

1. During the tour of the facility on May 21, 2013 at 9:00 a.m., room A was observed to have a penetration into the wall below the sink where the P Trap entered the wall.

2. On May 21, 2013 at 9:06 a.m., room B was observed to have a penetration into the wall below the sink where the P Trap entered the wall.

3 On May 21, 2013 at 9:18 a.m., rooms 310 and 312 was observed to have the covers missing to the communication wires box allowing a penetration in to the wall.

4 On May 21, 2013 at 9:35 a.m., room 209, 211, 212 and 215 was observed to have penetrations into the wall below the sink where the P Trap from the sink entered the wall.

Based on observations made on May 21, 2013, the facility did not ensure all window dressings were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics. The deficiency could affect a very limited amount of residents, patients and visitors in 1 of 4 smoke compartments on the main floor.

Findings included:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

During a tour of the facility on May 21, 2013 at 9:10 a.m., the newly hung curtains in the beauty shop and the activities room were not treated with a flame retardant.

An interview with the maintenance supervisor revealed that "The curtains were just hung and I have not treated them yet."

Based on observations made on May 21, 2013, the facility failed to assure that smoke dampers located in smoke compartments closed upon the activation of the fire alarm system. This deficiency could affect more than a limited number of residents, staff and visitors in two of the four smoke compartments on the main level of the building.

The findings include:

The smoke detection system of the facility is interconnected to the fire alarm system and activation of the fire alarm system should result in all smoke dampers being closed. A fire drill was conducted at 1:30 p.m. on May 21, 2013 and the two smoke dampers above the smoke barrier doors to the 100 wing and two above 300 wing were observed for closing purposes. The smoke dampers did not close as required when the fire alarm was activated.

Based on observations made on May 21, 2013, the facility failed to maintain the fire and smoke resistance rating of a wall assembly in a building of Type V (111) construction. The deficiency could affect a very limited amount of residents, staff, and visitors in two of seven smoke compartments.

The findings include:

1. During the tour of the facility on May 21, 2013 at 9:00 a.m., room A was observed to have a penetration into the wall below the sink where the P Trap entered the wall.

2. On May 21, 2013 at 9:06 a.m., room B was observed to have a penetration into the wall below the sink where the P Trap entered the wall.

3 On May 21, 2013 at 9:18 a.m., rooms 310 and 312 was observed to have the covers missing to the communication wires box allowing a penetration in to the wall.

4 On May 21, 2013 at 9:35 a.m., room 209, 211, 212 and 215 was observed to have penetrations into the wall below the sink where the P Trap from the sink entered the wall.

Based on observations made on May 21, 2013, the facility did not ensure all window dressings were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics. The deficiency could affect a very limited amount of residents, patients and visitors in 1 of 4 smoke compartments on the main floor.

Findings included:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

During a tour of the facility on May 21, 2013 at 9:10 a.m., the newly hung curtains in the beauty shop and the activities room were not treated with a flame retardant.

An interview with the maintenance supervisor revealed that "The curtains were just hung and I have not treated them yet."

Based on observations made on May 21, 2013, the facility failed to assure that smoke dampers located in smoke compartments closed upon the activation of the fire alarm system. This deficiency could affect more than a limited number of residents, staff and visitors in two of the four smoke compartments on the main level of the building.

The findings include:

The smoke detection system of the facility is interconnected to the fire alarm system and activation of the fire alarm system should result in all smoke dampers being closed. A fire drill was conducted at 1:30 p.m. on May 21, 2013 and the two smoke dampers above the smoke barrier doors to the 100 wing and two above 300 wing were observed for closing purposes. The smoke dampers did not close as required when the fire alarm was activated.