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Based on observation, the facility failed to provide partitions that resist the passage of smoke in a partial sprinkled building.

Findings include:

While inspecting corridor walls on 06-13-12 at 10:29 a.m., the surveyor and maintenance supervisor observed open corridor wall penetrations between X-ray waiting room and medical records.

This deficient practice affects 1 of 4 smoke compartments.

The maintenance supervisor and the administrator 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 affects 1 of 4 smoke compartments.

Findings include:

During the survey on June 13, 2012, the maintenance supervisor and the surveyor found the following rooms being used for storage:

1) The storage room door near social services does not have an automatic door closure installed.
2) The central supplies room has open penetrations and requires an automatic door closure installed.
3) The wall of the boiler room has open penetrations to the main building.

On June 13, 2012, the maintenance supervisor and the administrator were notified during the exit conference.

Based on observation, the facility failed to provide partitions that resist the passage of smoke in a partial sprinkled building.

Findings include:

While inspecting corridor walls on 06-13-12 at 10:29 a.m., the surveyor and maintenance supervisor observed open corridor wall penetrations between X-ray waiting room and medical records.

This deficient practice affects 1 of 4 smoke compartments.

The maintenance supervisor and the administrator 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 affects 1 of 4 smoke compartments.

Findings include:

During the survey on June 13, 2012, the maintenance supervisor and the surveyor found the following rooms being used for storage:

1) The storage room door near social services does not have an automatic door closure installed.
2) The central supplies room has open penetrations and requires an automatic door closure installed.
3) The wall of the boiler room has open penetrations to the main building.

On June 13, 2012, the maintenance supervisor and the administrator were notified during the exit conference.