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Based on observation and interview, the facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and would allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire-resistive rating of the smoke barriers. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 20 and a census of 3.

Findings include:

Observation and interview on 03/09/16 at 9:02 a.m., revealed the facility had a waiver for all penetrations above the suspended ceiling for all smoke barriers. The Plant Engineering Coordinator and Supervisor confirmed this previous waivered item had not been corrected at the time time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects 1 staff in 1 of 6 smoke zones. This facility has a capacity of 20 and a census of 3.

Findings include:

Observation and interview on 03/09/16 at 11:18 a.m., revealed the Director of Health Foundations Office contained a surge protector being used to supply power to a microwave and an adding machine. The Plant Engineering Coordinator and Supervisor verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were properly installed in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition. This deficient practice affects approximately 4 staff in 2 of 6 smoke zones. This facility has a capacity of 20 and a census of 3.

Findings include:

1. Observation and interview on 03/09/16 at 10:59 a.m., revealed Room #0058 contained a foam Alcohol Based Hand Rub (ABHR) dispenser located above and adjacent to an electrical outlet.

2. Observation and interview on 03/09/16 at 11:35 a.m., revealed Room #0002 contained a foam Alcohol Based Hand Rub (ABHR) dispenser located above and adjacent to an electrical outlet. The Plant Engineering Coordinator and Supervisor verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and would allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire-resistive rating of the smoke barriers. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 20 and a census of 3.

Findings include:

Observation and interview on 03/09/16 at 9:02 a.m., revealed the facility had a waiver for all penetrations above the suspended ceiling for all smoke barriers. The Plant Engineering Coordinator and Supervisor confirmed this previous waivered item had not been corrected at the time time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects 1 staff in 1 of 6 smoke zones. This facility has a capacity of 20 and a census of 3.

Findings include:

Observation and interview on 03/09/16 at 11:18 a.m., revealed the Director of Health Foundations Office contained a surge protector being used to supply power to a microwave and an adding machine. The Plant Engineering Coordinator and Supervisor verified this observation at the time of the survey process.