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Tag No.: K0372
Based on observations, the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with NFPA 101 19.3.7.3, 8.5, 8.5.6. These deficient practices have the potential of affecting three (3) of three (3) smoke compartments and all 19 patients in the facility on the day of survey.
Findings include:
On March 1, 2017 at 11:45 AM, observations revealed unsealed penetrations and unapproved fire sealant (sheetrock mud and foam spray) in the smoke barrier walls near the Behavior Health Unit and the Emergency Department of the facility.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.
Tag No.: K0374
Based on observations, the facility failed to provide and maintain smoke barrier doors in accordance with 19.3.7.8. This deficient practice has the potential to affect two (2) of three (3) smoke compartments and all 19 patients in the facility on the day of survey.
Findings include:
On March 1, 2017 at 12:35 AM, observations revealed the smoke barrier doors near the Behavior Health Unit did not close during activation of the fire alarm and sprinkler system tests. The smoke barrier doors were unleveled and got obstructed by the floor of facility.
The administrator and maintenance director were notified during the survey and in the exit conference.