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Based on observation and staff interview during the survey on Aug 24, 2021, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101, section 18.3.5, 18.3.5.1, 9.7, and NFPA 13. The following evidenced this:

1) No sprinkler coverage in storage closet in Sleep Lab.

The Sprinkler System deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Maintenance Director acknowledged the sprinkler system deficiency.

Based on record review, observation and staff interview during the course of the survey conducted on Aug 24, 2021, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 18.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this:

1) Fire sprinkler head in Boiler Room is covered with a rag - CORRECTED DURING SURVEY
2) Fire sprinkler head in Trauma room is obstructed by overhead lift.
3) Storage within 18" of fire sprinkler head in Admin File Storage. - CORRECTED DURING SURVEY
4) Storage within 18" of fire sprinkler head in HIM storage room. - CORRECTED DURING SURVEY

The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation and staff interview during the course of the survey conducted on August 24, 2021, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 18.3.7.3 including 8.5. The following evidenced this:

During the walk-through with the Maintenance Supervisor;
1) Multiple penetrations in IT server room - CORRECTED DURING SURVEY
2) Electrical room by Pharmacy has penetration around fire/smoke damper - CORRECTED DURING SURVEY
3) Penetration in fire pump room - CORRECTED DURING SURVEY
4) Penetration in Med Gas room - CORRECTED DURING SURVEY

Maintenance Director acknowledged the deficiency during a tour of the facility.
The smoke barrier deficiency has the potential to affect all occupants, who might include staff and visitors in all associated compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code Section 18.3.7.3, in part, smoke barrier walls constructed in accordance with Section 8.5 with a minimum of 1 hour fire resistive rating.