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Based on observations, the facility failed to provide a one half hour rating in accordance with NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.The deficient practice affected four (4) of four (4) smoke compartments on the day of the survey.

Findings Include:

On 6/22/16 at 2:55 PM, observation revealed open penetrations in the following areas of the smoke barrier walls:

1) Smoke barrier wall leading to Emergency Room Suite
2) Smoke barrier wall near Room 102
3) Smoke barrier wall near Room 125
4) Smoke barrier wall near Room 111

The maintenance personnel were advised that we will do a full inspection of smoke barrier walls upon revisit.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 6/22/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 19.3.7.3. The deficient practice affected three (3) of four (4) smoke compartments on the day of the survey.

Findings Include:

On 6/22/16 at 3:25 PM, observation revealed the following deficiencies of the hazardous areas of the facility.

1) Boiler Room has open penetrations.
2) Storage Room near Room 109 has open penetrations.
3) Communications Room near Laboratory has open penetrations.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 6/22/16.

Based on document review, the facility failed to provide the required annual Fire Alarm testing in accordance with NFPA 72. The deficient practice affected all four (4) compartments of the facility.

Findings Include:

While reviewing fire alarm documentation on 6/22/16 at 2:00PM, the surveyor observed the facility could not provide annual inspection documentation within the last year. The last inspection of the fire alarm was May 2015.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/22/16.

Based on observations, the facility failed to provide a one half hour rating in accordance with NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.The deficient practice affected four (4) of four (4) smoke compartments on the day of the survey.

Findings Include:

On 6/22/16 at 2:55 PM, observation revealed open penetrations in the following areas of the smoke barrier walls:

1) Smoke barrier wall leading to Emergency Room Suite
2) Smoke barrier wall near Room 102
3) Smoke barrier wall near Room 125
4) Smoke barrier wall near Room 111

The maintenance personnel were advised that we will do a full inspection of smoke barrier walls upon revisit.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 6/22/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 19.3.7.3. The deficient practice affected three (3) of four (4) smoke compartments on the day of the survey.

Findings Include:

On 6/22/16 at 3:25 PM, observation revealed the following deficiencies of the hazardous areas of the facility.

1) Boiler Room has open penetrations.
2) Storage Room near Room 109 has open penetrations.
3) Communications Room near Laboratory has open penetrations.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 6/22/16.

Based on document review, the facility failed to provide the required annual Fire Alarm testing in accordance with NFPA 72. The deficient practice affected all four (4) compartments of the facility.

Findings Include:

While reviewing fire alarm documentation on 6/22/16 at 2:00PM, the surveyor observed the facility could not provide annual inspection documentation within the last year. The last inspection of the fire alarm was May 2015.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/22/16.