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Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to t he other in the facility. The deficient practice had the potential to affect 25 patients
1 of 3 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:15 and 11:30 if was found that there was an unsealed conduit in 2 hr wall in Central Supply storage room located on 2nd floor.

1st Floor
1] There were unsealed holes in 2 hr wall over corridor doors at Ultra Sound room
2]There was an unsealed conduit in 2 hr wall in Lab storage room
3]There were unsealed wires in 2 hr wall across from Physicians Only Door

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility.The defecient practive had the ability to affect.
1 of 3 smoke barriers .

Findings:

During the facility tour, between the hours of 12:30 and 3:30 if was found that
1]Unsealed conduit in 2 hr wall 2 west hallway
2]Unsealed holes in equipment storage and air handler room 2 hr wall

Interview with Maintenance supervisor revealed the facility was not aware of unsealed penetrations.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. Doors shall be self-closing and positive latching.

Findings:

During the facility tour, between the hours of 9:15 and 11:30 if was found on 3rd floor
1]Respiratory Therapy storage room had holes around old sprinkler lines that needed to be sealed.
2]Provide door closure for door to Respiratory Therapy storage room.
3]Provide door closure to File Room office

2nd Floor
1]Seal walls in Equipment Storage room around pipes and wires.

Interview with Maintenance supervisor revealed the facility was not aware of the walls of the hazardous areas having unsealed penetrations and not having door closures on doors.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to t he other in the facility. The deficient practice had the potential to affect 25 patients
1 of 3 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:15 and 11:30 if was found that there was an unsealed conduit in 2 hr wall in Central Supply storage room located on 2nd floor.

1st Floor
1] There were unsealed holes in 2 hr wall over corridor doors at Ultra Sound room
2]There was an unsealed conduit in 2 hr wall in Lab storage room
3]There were unsealed wires in 2 hr wall across from Physicians Only Door

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility.The defecient practive had the ability to affect.
1 of 3 smoke barriers .

Findings:

During the facility tour, between the hours of 12:30 and 3:30 if was found that
1]Unsealed conduit in 2 hr wall 2 west hallway
2]Unsealed holes in equipment storage and air handler room 2 hr wall

Interview with Maintenance supervisor revealed the facility was not aware of unsealed penetrations.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. Doors shall be self-closing and positive latching.

Findings:

During the facility tour, between the hours of 9:15 and 11:30 if was found on 3rd floor
1]Respiratory Therapy storage room had holes around old sprinkler lines that needed to be sealed.
2]Provide door closure for door to Respiratory Therapy storage room.
3]Provide door closure to File Room office

2nd Floor
1]Seal walls in Equipment Storage room around pipes and wires.

Interview with Maintenance supervisor revealed the facility was not aware of the walls of the hazardous areas having unsealed penetrations and not having door closures on doors.