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Based on observations made during the survey of the facility between the hours of 8:30 am and 12:30 pm, while accompanied by the Administrator/CEO, and Maintenance Director it was observed that the facility was not in compliance regarding HAZARDOUS AREAS - ENCLOSURE.

The facility was unable to adequately identify HAZARDOUS AREA locations with required 1 HOUR FIRE-RATED WALL construction for the ENCLOSURE. Provide the following:

RECORD DRAWINGS IN REGARDS TO HAZARDOUS AREAS - ENCLOSURE: The above mentioned Hospital Record Drawings for the LIFE SAFETY FLOOR PLAN shall also indicate proper labeling of all other required rated construction relating to Life Safety Requirements. These drawings shall be prepared by Design Professionals licensed in the State of Texas, and shall include the Design Professional's Seal, Signature, and Date.

Based on observations made during the survey of the facility between the hours of 8:30 am and 12:30 pm, while accompanied by the Administrator/CEO, and Maintenance Director it was observed that the facility was not in compliance regarding SUBDIVISION OF BUILDING SPACES - SMOKE COMPARTMENTS. The facility was unable to adequately identify locations for the required 1 HOUR FIRE/SMOKE BARRIER WALL(s) construction separating the SMOKE COMPARTMENTS.

Additionally, the facility was unable to adequately identify locations of other types of Fire-Rated construction. The integrity of this Life Safety Protection construction is required to be routinely maintained and inspected. In addition, Hospital Personnel (including Care Givers) are to be educated and trained in how to utilized the Life Safety Protection that the built environment is required to offer to Building Occupants (including Patients, Visitors, Staff, and Emergency Response Teams). Provide the following:

RECORD DRAWINGS IN REGARDS TO SMOKE COMPARTMENTATION - Hospital Record Drawings shall include a LIFE SAFETY FLOOR PLAN indicating the labeling of each of the various SMOKE COMPARTMENTS, as well as the location and extent of the required SMOKE COMPARTMENTS. These drawings shall be prepared by Design Professionals licensed in the State of Texas, and shall include the Design Professional's Seal, Signature, and Date.

Based on observations made during the survey of the facility between the hours of 8:30 am and 12:30 pm, while accompanied by the Administrator/CEO, and Maintenance Director it was observed that the facility was not in compliance regarding SUBDIVISION OF BUILDING SPACES - ACCUMULATION SPACE. Without clarity of definition of Smoke Compartmentation, the requirement for properly allocated ACCUMULATION SPACE needs to be verified based on forthcoming LIFE SAFETY FLOOR PLAN DRAWING.

Based on observations made during the survey of the facility between the hours of 8:30 am and 12:30 pm, while accompanied by the Administrator/CEO, and Maintenance Director it was observed that the facility was not in compliance regarding SUBDIVISION OF BUILDING SPACES - SMOKE BARRIER DOORS. Without clarity of definition of Smoke Compartmentation, compliance on SMOKE BARRIER DOORS will be contingent upon forthcoming LIFE SAFETY FLOOR PLAN DRAWING.