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Based on observations, the facility failed to properly maintain smoke barrier walls in accordance to NFPA 101 section 8.3, 19.3.7.3, 19.3.7.5. This deficient practice had the potential of affecting the entire facility on the day of survey.

Findings Include:

On 2/17/16 at 12:00 PM, observation revealed the smoke barrier wall near the Nurses Station had unsealed penetrations on both sides of the wall above the ceiling.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 2/17/16.

This standard is not met as evidenced by:

Based on observations, the facility failed to provide a complete manual fire alarm system in accordance to NFPA 101 section 9.6 and NFPA 72 section 4-4.4.2.3. This deficient practice had the potential of affecting the entire facility on the day of survey.

Findings Include:

On 2/17/16 at 12:30 PM, observation revealed the visual fire alarm signaling devices (strobe lights) were not synchronized in the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 2/17/16.

4-4.4.2.3

In corridors where there are more than two visible notification
appliances in any field of view, they shall be spaced a minimum
of 55 ft (16.76 m) from each other or they shall flash in
synchronization.

Based on observations, the facility failed to properly maintain smoke barrier walls in accordance to NFPA 101 section 8.3, 19.3.7.3, 19.3.7.5. This deficient practice had the potential of affecting the entire facility on the day of survey.

Findings Include:

On 2/17/16 at 12:00 PM, observation revealed the smoke barrier wall near the Nurses Station had unsealed penetrations on both sides of the wall above the ceiling.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 2/17/16.

This standard is not met as evidenced by:

Based on observations, the facility failed to provide a complete manual fire alarm system in accordance to NFPA 101 section 9.6 and NFPA 72 section 4-4.4.2.3. This deficient practice had the potential of affecting the entire facility on the day of survey.

Findings Include:

On 2/17/16 at 12:30 PM, observation revealed the visual fire alarm signaling devices (strobe lights) were not synchronized in the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 2/17/16.

4-4.4.2.3

In corridors where there are more than two visible notification
appliances in any field of view, they shall be spaced a minimum
of 55 ft (16.76 m) from each other or they shall flash in
synchronization.