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Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on August 21, 2014 at 11:15 a.m., the maintenance person and surveyor found the following areas to be used as storage and the doors of these areas also did not have a self closing device:

1. Rooms 210 and 212 on 2nd Floor East Wing
2. Rooms 215, 220, and 221 on 2nd Floor South Wing
3. Room 229 on 2nd Floor North Wing

These deficient practices have the potential of affecting 3 of 8 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. NFPA 72 Section 1-5.6

Findings include:

On August 20, 2014 at 11:00 a.m., the maintenance supervisor and surveyor observed that all emergency strobes lights need to be synchronized in all the smoke compartments of the facility.

This condition had the potential to affect the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation, the facility failed to provide task illumination at the generator transfer in accordance with NFPA 99 3-4.2.2.2.

Finding include:

On August 20, 2014 at 1:15 p.m., the maintenance supervisor and surveyor observed no battery emergency light at the generator transfer switch in the Electrical Room.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on August 21, 2014 at 11:15 a.m., the maintenance person and surveyor found the following areas to be used as storage and the doors of these areas also did not have a self closing device:

1. Rooms 210 and 212 on 2nd Floor East Wing
2. Rooms 215, 220, and 221 on 2nd Floor South Wing
3. Room 229 on 2nd Floor North Wing

These deficient practices have the potential of affecting 3 of 8 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. NFPA 72 Section 1-5.6

Findings include:

On August 20, 2014 at 11:00 a.m., the maintenance supervisor and surveyor observed that all emergency strobes lights need to be synchronized in all the smoke compartments of the facility.

This condition had the potential to affect the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation, the facility failed to provide task illumination at the generator transfer in accordance with NFPA 99 3-4.2.2.2.

Finding include:

On August 20, 2014 at 1:15 p.m., the maintenance supervisor and surveyor observed no battery emergency light at the generator transfer switch in the Electrical Room.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.