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Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect occupants in 1 of 3 smoke compartments in the event of smoke passage through a fire barrier.

Findings Include:

1. In an observation on 5/1/17 at 12:25 PM, an open pipe penetration at the ceiling of the Basement Trash Room had not been sealed with an approved fire stopping system in accordance with NFPA 101, Section 8.7.1 and Section 8.3.5

- In an interview on 5/1/17 at 12:25 PM, maintenance staff member #1 confirmed an open pipe penetration at the ceiling of the Basement Trash Room had not been sealed with an approved fire stopping system.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect all occupants in the event of a fire if the automatic sprinkler system failed to function as designed due to a lack of maintenance.

Findings Include:

1. In an observation on 5/1/17 at 11:00 AM, a damaged ceiling tile was observed proximate to a sprinkler head at the entrance to the POLAR Long Term Care occupancy in violation of NFPA 25, Section 5.1 and NFPA 13, Section 8.1.1(3)

- In an interview on 5/1/17 at 11:00 AM, maintenance staff member #1 confirmed a damaged ceiling tile was observed proximate to a sprinkler head at the entrance to the POLAR Long Term Care occupancy.

2. In an observation on 5/1/17 at 11:40 AM, a damaged ceiling tile was observed proximate to a sprinkler head in the Lab Storage Room in violation of NFPA 25, Section 5.1 and NFPA 13, Section 8.1.1(3)

- In an interview on 5/1/17 at 11:40 AM, maintenance staff member #1 confirmed a damaged ceiling tile was observed proximate to a sprinkler head in the Lab Storage Room.

3. In an observation on 5/1/17 at 11:45 AM, a communication wire was observed attached to a sprinkler pipe above the ceiling near the Lab Toilet Room in violation of NFPA 25, Section 5.1 and NFPA 13, Section 9.1.1.7

- In an interview on 5/1/17 at 11:45 AM, maintenance staff member #1 confirmed a communication wire was observed attached to a sprinkler pipe above the ceiling near the Lab Toilet Room.

Based upon observation and interview, the facility failed to ensure that electrical wiring and equipment complies with NFPA 70 as required by 9.1.2. This deficient practice could affect occupants in 1 of 3 smoke compartments in the event of a fire due to an electrical fault causing a fire.

Findings Include:

1. In an observation on 5/1/17 at 11:10 AM, an open junction box was observed above the ceiling near the Environmental Services Closet and Penthouse access in violation of NFPA 101, Section 9.1.2 and NFPA 70, Article 314.25

- In an interview on 5/1/17 at 11:10 AM, maintenance staff member #1 confirmed an open junction box was observed above the ceiling near the Environmental Services Closet and Penthouse access.

Based upon records review and interview, the facility failed to ensure that fire drills includes the transmission of a fire alarm signal, simulation of emergency fire conditions, are held at unexpected times under varying circumstances, and conducted at least quarterly on each shift as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect all occupants of the facility, if staff are not properly trained in approved emergency procedures.

Findings Include:

1. During a review of records on 5/1/17 at 10:10 AM, no fire drills were documented as having been conducted during weekends therefore not meeting the varying conditions requirement in accordance with NFPA 101, Section 19.7.1.6

- In an interview during a review of records on 5/1/17 at 10:10 AM, maintenance staff member #1 confirmed no fire drills had been conducted during weekends therefore not meeting the varying conditions requirement.