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Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 18 of 18 residents.
2 of 2 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 12:30PM and 4:30PM on 11/10/15, it was observed that the smoke barriers by room 322 and 340 had unprotected penetrations.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 18 of 18 residents.

Findings:

During the facility tour and the record review, between the hours of 12:30PM and 4:30PM on 11/10/15 it was observed that the fire alarm system was not functional and red tagged by the fire alarm contractor. The facility is currently operating a fire watch.

Based on visual observation the facility failed to provide testing on the building smoke detectors that are connected to the fire alarm system. The detectors offer a means of activating the fire alarm system to provide emergency notification to the occupants of the building. This deficiency has the potential to affect 18 of 18 residents.

Findings:

During the facility tour, between the hours of 12:30PM and 4:30PM on 11/10/15, it was observed that the smoke detectors in the corridors were not in operation due to the fire alarm system not functioning.

Interview with Administrator revealed the facility was not aware that the smoke detectors were not in operation.

Based on visual observation the facility failed to assure all areas of the building were protected by the supervised, automatic sprinkler system installed in accordance with NFPA 13 in 2 of 4 mechanical rooms. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 40 of 40 residents.

Findings:

During the facility tour the 9th and 10th 30 wing mechanical rooms were observed having a 5 foot duct with no sprinkler head installed protecting the area beneath the obstruction.

Interview with the maintenance supervisor revealed the facility was not aware sprinkler heads in these areas had been omitted.

Based on visual observation the facility failed to provide a fire alarm system that is activated by manual means, detection devices and waterflow alarms. When the building is equipped with life safety systems, that offer complete coverage, the occupants maintain a sense of security in an emergency. This deficiency has the potential to affect 18 of 18 residents.

Findings:

During the record review, between the hours of 12:30PM and 4:30PM on 11/10/15, it was observed that the fire alarm system was not in operation and a fire watch was currently being conducted.

Interview with Administrator revealed the facility was not aware the automatic sprinkler system would not activate the fire alarm system.

Based on visual observation the facility failed to assure that the automatic sprinkler system has supervised valves that will sound a local alarm if closed. A direct result, of the fire alarm system being notified of the emergency, is protection of life and property. This deficiency has the potential to affect 18 of 18 residents.

Findings:

During the facility tour, between the hours of 12:30PM and 4:30PM on 11/10/15, it was observed that the fire alarm system was not in operation and would not activate if the sprinkler valves were closed.

Interview with Administrator revealed the facility was not aware that the valves on the sprinkler system were not supervised by the fire alarm system.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 18 of 18 residents.

Findings:

During the facility tour, between the hours of 12:30PM and 4:30PM on 11/10/15, it was observed that the junction boxes located above the ceiling in the corridor were left uncovered and had exposed wiring.

Interview with Administrator revealed the facility was not aware of the (EXAMPLE: uncovered electrical panel, open junction box, exposed wires, etc.) .