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Based on interview, record review, and observation, the facility failed to maintain the rating to barriers protecting vertical openings, to ensure doors with means to stay closed to protect corridor openings, stay closed, to maintain the stated ratings of barriers, to ensure doors in two barriers were rated, to ensure barriers in hazardous areas were free of penetrations, and to ensure all dampers were tested (A709). This has the potential to affect all patients and visitors to the facility. The census of the facility was 568 patients.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. The census of the facility was 568 patients.

Findings include:

K20 Failed to maintain the stated ratings of barriers protecting vertical openings.

K18 Failed to ensure doors with means to stay closed to protect corridor openings, stay closed.

K25 Failed to maintain the stated ratings of barriers.

K27 Failed to ensure doors in two barriers were rated.

K29 Failed to ensure barriers in hazardous areas were free of penetrations.

K67 Failed to ensure all dampers were tested.