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Based on observation and interview with facility staff the facility failed to ensure smoke barriers walls are properly maintained. In the event of a fire all residents and staff may be affected.
Reference: 2000 Life Safety Code 8.3 and 18.3.7.3
Findings Include:
On 05/23/2016 between 9:30 a.m. and 2:00 p.m. observation revealed penetrations in the smoke barrier above the double doors near the D.O.N. office, unsealed conduit penetrations in the smoke barrier at Respiratory Therapy, penetrations in the smoke barrier in the staff lounge, ends of sleeves not fire stopped in the smoke barrier above the double doors at the Pharmacy, plumbing penetration not sealed with approved fire stop material in the smoke barrier in the ER Lounge, and conduit penetrations are not sealed with approved fire stop materials in the smoke barrier at the ER Isolation room.
Staff member M confirmed the findings at the time of discovery.

Based on observation and interview with facility staff the facility failed to ensure fire barriers at one of several hazardous areas were not properly maintained. In the event of a fire 5 of the 25 occupants may be affected.
Reference:2000 Life Safety Code 8.4 and 18.3.2.1
Findings include:
On 5/23/2016 between 9:30am and 2:00pm observation revealed Insulated plumbing pipe penetration in 1 hour wall was not fire stopped in plant operations.
Staff member M confirmed the findings at the time of discovery.

Based on review of facility records and interview with facility staff showed missing records of fire drills.
Reference: 2000 Life Safety Code 18.7.1.1
Findings include:
On 5/23/2016 between 9:30am and 2:00pm review of records showed facility failed to perform fire drills for the 3rd period of 2015 dayshift and no record of a drill on the 2nd and 4th quarters of night shift.
Staff member M confirmed the findings at the time of discovery.

Based on record reviews and interview with facility staff. The facility failed to maintain proper maintenance of the smoke detection system. In the event of a fire all occupants may be affected.
Reference: 2000 Life Safety Code 9.6 and 18.3.4.5.1
Findings Include:
On 5/23/2016 between 9:30am and 2:00pm review of records showed facility failed to perform smoke detector sensitivity testing for last 2 years on the smoke detection system.
Staff member M confirmed the findings at the time of discovery.

Based on review of sprinkler maintenance records no quarterly records were found. In the event of a fire all occupants may be affected.
Reference: 2000 Life Safety Code 9.7.5, NFPA 25
Findings include:
On 5/23/2016 between 9:30am and 2:00pm a review of records showed no Quarterly maintenance was performed on sprinkler system.
Staff member M confirmed the findings at the time of discovery.