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Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 100% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on December 11, 2012 at 11:00 a.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located next to the emergency department entrance had a penetration around the computer cables.

This deficient practice has the potential of affecting 2 of 2 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 50% of the resident.

Findings include:

While inspecting hazardous areas on December 11, 2012 at 11:30 a.m., the maintenance supervisor and the surveyor observed the gas fired Water Heater Room located behind the kitchen had numerous penetrations.

This deficient practice has the potential of affecting 1 of 2 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required Fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings include:

While reviewing fire drill documentation on December 11, 2012 at 12:30 p.m., the surveyor observed the facility could not provide fire drill information for past fire drills including date, time, what shift, and personnel attending the fire drill. The maintenance director stated that he was not aware he had to perform fire drills.

The administrator and the maintenance director were notified during the facility as well as the exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff as all smoke compartments were affected.

Findings include:

While reviewing sprinkler documentation on December 11, 2012 at 12:45 p.m., the facility could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

The maintenance supervisor and the administrator were notified during the exit conference.