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Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice affected 1 of 8 smoke compartments.

Findings include:

On December 19, 2011 at 1:00 p.m., the maintenance person and the the surveyor found the Old Patients Account Room was being used for storage. The room did not have 45 minute rated doors or automatic door closers installed.

The maintenance supervisor and the administrator were notified during the exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 2 smoke compartments.

Findings include:

On December 19, 2011 at 1:30 p.m., the maintenance person and surveyor found that the horn/strobe located in the ICU and Surgery suites did not activate properly when the fire alarm was activated. The horn/strobes would not stay activated after the alarm was activated.

The maintenance supervisor and the administrate were notified during an exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice affected 1 of 8 smoke compartments.

Findings include:

On December 19, 2011 at 1:00 p.m., the maintenance person and the the surveyor found the Old Patients Account Room was being used for storage. The room did not have 45 minute rated doors or automatic door closers installed.

The maintenance supervisor and the administrator were notified during the exit conference.

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 2 smoke compartments.

Findings include:

On December 19, 2011 at 1:30 p.m., the maintenance person and surveyor found that the horn/strobe located in the ICU and Surgery suites did not activate properly when the fire alarm was activated. The horn/strobes would not stay activated after the alarm was activated.

The maintenance supervisor and the administrate were notified during an exit conference.