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Based on observation and staff interview, the facility failed to provide smoke resisting partitions for hazardous areas in 2 of 6 smoke compartments. This condition had the potential to allow smoke and fire to migrate from a hazardous area into the exit corridors or use areas. Facility census was 5.

Findings are:
Observations during the facility tour on 2/4/13, from 12:37 pm to 12:54 pm revealed:
1. The OR Storage Room Door failed to automatically close and latch. A trash can obstructed the door, and prevented the door from closing.
2. Penetrations around copper pipes in the wall of the Hospital Pharmacy Storage Room between the ER failed to be sealed.
3. Penetrations around pipes in the west wall of the Clinic Air Handler Room failed to be sealed.
In an interview conducted at the time of observation, (2/4/13, from 12:37 pm to 12:54 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to install the sprinkler system in accordance with the National Fire Protection Association, 13 in 1 of 6 smoke compartments. This condition had the potential that the sprinkler heads would fail to suppress a fire as designed. Facility census was 5.

Findings are:
Observations during the facility tour on 2/4/13, at 12:41 pm revealed:
1. The Maintenance Hallway had partial sprinkler protection. A barrier to separate the sprinkled area from the non-sprinkled area failed to exist.
2. The north and south patient room halls had partial sprinkler protection. A barrier to separate the sprinkled areas from the non-sprinkled areas failed to exist.
In an interview conducted at the time of observation, (2/4/13, at 12:41 pm), Maintenance A confirmed the areas that failed to be sprinkler protected.

Actual NFPA Standard:
Nebraska State Fire Marshal Official Interpretation 03-07

Based on observation and staff interview, the facility failed to provide smoke resisting partitions for hazardous areas in 2 of 6 smoke compartments. This condition had the potential to allow smoke and fire to migrate from a hazardous area into the exit corridors or use areas. Facility census was 5.

Findings are:
Observations during the facility tour on 2/4/13, from 12:37 pm to 12:54 pm revealed:
1. The OR Storage Room Door failed to automatically close and latch. A trash can obstructed the door, and prevented the door from closing.
2. Penetrations around copper pipes in the wall of the Hospital Pharmacy Storage Room between the ER failed to be sealed.
3. Penetrations around pipes in the west wall of the Clinic Air Handler Room failed to be sealed.
In an interview conducted at the time of observation, (2/4/13, from 12:37 pm to 12:54 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to install the sprinkler system in accordance with the National Fire Protection Association, 13 in 1 of 6 smoke compartments. This condition had the potential that the sprinkler heads would fail to suppress a fire as designed. Facility census was 5.

Findings are:
Observations during the facility tour on 2/4/13, at 12:41 pm revealed:
1. The Maintenance Hallway had partial sprinkler protection. A barrier to separate the sprinkled area from the non-sprinkled area failed to exist.
2. The north and south patient room halls had partial sprinkler protection. A barrier to separate the sprinkled areas from the non-sprinkled areas failed to exist.
In an interview conducted at the time of observation, (2/4/13, at 12:41 pm), Maintenance A confirmed the areas that failed to be sprinkler protected.

Actual NFPA Standard:
Nebraska State Fire Marshal Official Interpretation 03-07