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Based on schematic review, observation, and interview, the facility failed to ensure the identified fire rated smoke barriers were maintained, fire rating of vertical opens were maintained, occupancy separation wall fire ratings were maintained, self closing doors in occupancy separation walls closed to latching position and the releasing devices were tested, the fire rating of hazardous area walls were maintained, notification devices were tested at least annually, fire drills were held at varying times, and hospital grade receptacles initial testing was completed and documented. (A 709) The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of all patients receiving services at the facility.

Findings include:

See A709

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically chapter 21 of the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association 101. This had the potential to affect all patients receiving services at the facility.

Findings include:

1. Please see K131 for findings related to the facility failing to maintain the fire rating of occupancy separations.

2. Please see K223 for findings related to the facility failing to ensure door releasing devices were tested.

3. Please see K311 for findings related to the facility failing to maintain the fire rating of vertical openings.

4. Please see K321 for findings related to the facility failing to ensure the identified 1 hour fire rated walls for the hazardous areas were free of penetrations.

5. Please see K345 for findings related to the facility failing to ensure horns and strobes were tested at least annually.

6. Please see K372 for findings related to the facility failing to ensure the 1 hour smoke barrier was free of penetrations.

7. Please see K712 for findings related to the facility failing to ensure fire drills were held at varying times.

8. Please see K914 for findings related to the facility failing to ensure hospital grade receptacle initial testing was completed.

This deficiency substantiates Substantial Allegations OH00099615 and OH00099617.