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Based on observation and interview with staff, the facility failed to provide self-closing doors to protect hazardous areas. Finding:

The door to the clean linen storage room was not provided with a closure.

Based on review of the facilities " Fire Drill Evaluation" report form, the facility failed to ensure the staff is familiar with procedures. Finding:

The Fire Drill Evaluation form failed to establish who participated in drills.

Based on observation and interview with staff, the facility failed to maintain fire alarm systems in accordance with NFPA 72 and to keep records of maintenance readily available. Findings:

(1) The annual fire alarm report failed to include the combination fire and smoke dampers located at the combination fire and smoke walls and magnetic door locks. All equipment connected to the fire alarm system is required to be inspected once a year by an outside vendor.

(2) Repairs made on the fire alarm system were not documented by a re-acceptance test depicting work done, verification of system retest, and stating that when technician left the system was functional.

(3) Throughout the facility, smoke detectors were found less than 3 feet of air conditioning diffusers. Detectors are required to be greater than 3 feet from diffusers.

Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of section 9.2. Finding:

The soiled utility rooms were not provided with exhaust ducts to the outside.

Based on observation and interview with staff, the facility failed to provide battery powered lighting for the emergency power supply system transfer switch located in the electrical distribution room. NFPA 110, 2005 edition, NFPA 110 7.3.1

Based on observation and interview with staff, the facility failed to provide self-closing doors to protect hazardous areas. Finding:

The door to the clean linen storage room was not provided with a closure.

Based on review of the facilities " Fire Drill Evaluation" report form, the facility failed to ensure the staff is familiar with procedures. Finding:

The Fire Drill Evaluation form failed to establish who participated in drills.

Based on observation and interview with staff, the facility failed to maintain fire alarm systems in accordance with NFPA 72 and to keep records of maintenance readily available. Findings:

(1) The annual fire alarm report failed to include the combination fire and smoke dampers located at the combination fire and smoke walls and magnetic door locks. All equipment connected to the fire alarm system is required to be inspected once a year by an outside vendor.

(2) Repairs made on the fire alarm system were not documented by a re-acceptance test depicting work done, verification of system retest, and stating that when technician left the system was functional.

(3) Throughout the facility, smoke detectors were found less than 3 feet of air conditioning diffusers. Detectors are required to be greater than 3 feet from diffusers.

Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of section 9.2. Finding:

The soiled utility rooms were not provided with exhaust ducts to the outside.

Based on observation and interview with staff, the facility failed to provide battery powered lighting for the emergency power supply system transfer switch located in the electrical distribution room. NFPA 110, 2005 edition, NFPA 110 7.3.1