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Based on observation and interview with staff, the facility failed to provide the building with a construction type that meets NFPA 101 2000 edition 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1 Findings,

Holes and voids in the rated ceiling assembly are not sealed with material capable of maintaining the 1-hour fire resistance rating of the ceiling's UL assembly.

The two ceiling access doors to the attic space are not rated for the ceiling's 1-hour UL assembly. These attic access doors are located behind the 24 hour manned nurse's station and in the lab area.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3, 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings,

The smoke barrier wall in the attic space above the nurses station was provided with a door opening that is not protected with with at least a 20 minute rated assembly and closer. The door was open, which would allow fire and smoke to migrate throughout the entire attic.

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings,

The annual inspection completed on 1-4-2012 failed to show test of the combination fire and smoke dampers that are connected to the fire alarm system.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system, that is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. 19.3.5 Finding,

The wood-covered emergency entrance is not provided coverage with the sprinkler system.

Based on observation and interview with staff, the facility failed to provide an area alarm panel to all vital life su-port areas. NFPA 99, 4.3.1.2.2 Findings,

The Emergency Department is a Vital Life Support Area.

Based on observation and interview with staff, the facility failed to provide the building with a construction type that meets NFPA 101 2000 edition 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1 Findings,

Holes and voids in the rated ceiling assembly are not sealed with material capable of maintaining the 1-hour fire resistance rating of the ceiling's UL assembly.

The two ceiling access doors to the attic space are not rated for the ceiling's 1-hour UL assembly. These attic access doors are located behind the 24 hour manned nurse's station and in the lab area.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3, 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings,

The smoke barrier wall in the attic space above the nurses station was provided with a door opening that is not protected with with at least a 20 minute rated assembly and closer. The door was open, which would allow fire and smoke to migrate throughout the entire attic.

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings,

The annual inspection completed on 1-4-2012 failed to show test of the combination fire and smoke dampers that are connected to the fire alarm system.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system, that is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. 19.3.5 Finding,

The wood-covered emergency entrance is not provided coverage with the sprinkler system.

Based on observation and interview with staff, the facility failed to provide an area alarm panel to all vital life su-port areas. NFPA 99, 4.3.1.2.2 Findings,

The Emergency Department is a Vital Life Support Area.