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Based on observation and interview, the facility failed to maintain the smoke barrier in that penetrations had not been sealed with a material capable of maintaining the smoke resistance of the barrier in four of six areas observed. The failed practice had the potential to affect all patients, staff, and visitors because the space between the penetration and the smoke barrier would allow smoke to pass from one compartment to the next in the event of a fire and smoke event. The facility had an average monthly census of three on 06/15/15. Findings follow:

A. During a tour of the facility with the Maintenance Director on 06/16/15 at 1312, the following observations were made and verified:
1) Two large aluminum pipes penetrating the smoke barrier above the fire doors near Radiology were not sealed.
2) Internet cables penetrating the smoke barrier in two areas above the fire doors near patient Room #37 were not sealed.
3) Internet cables and electrical wire penetrating the smoke barrier above the firewall near the nurse station and patient Room #30 were not sealed.
4) Flexible electrical conduit and rigid electrical conduit penetrating the smoke barrier above the fire doors near the vending area and outpatient clinic were not sealed.

Based on documentation review and interview, it was determined that the facility failed to exercise the generator under load for 30 minutes every month for five of five months from January 2015 through May 2015. The failed practice had the potential to affect patients, visitors, and staff because the ability of the generator to provide power during load conditions was not assured. The facility had an average monthly census of three on 06/15/15. Findings follow:

A. During review of the Generator Log on 06/16/15 at 0940, it was determined that the generator had not been exercised under load conditions for 30 minutes each month.
B. During an interview on 06/16/15 at 1415 with the Maintenance Director and the Administrator it was confirmed the generator had not been exercised under load for 30 minutes each month.