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Based on observations, the facility failed to protect hazardous area in accordance with NFPA 101 section 19.3.2.1. This deficiency affected the entire facility at the time of survey.

Findings include:

On 7/12/23 between 9:30 AM and 11:20 AM, observation revealed the facility failed to protect the following hazardous areas of the facility:

The ceiling in the Phone Connection Room was not properly sealed.

The ceiling in the Boiler Room was not properly sealed.

The walls above the lay in ceiling in the Biohazard Room was not properly sealed.

The door of Soiled Utility/Soiled Laundry Room near Room 339 lacked an automatic door closer.

The Medical Records Room was missing a doorknob and was not smoke tight.


These hazardous were incapable of resisting the passage of smoke throughout the facility.


43981

Based on record review, the facility failed to provide a properly maintained fire alarm system as required by NFPA 72 Table 14.4.5.3.2. This deficiency affected the entire facility at the time of survey.

Findings include:

On 7/12/23 at 9:40 AM observation and record review revealed the facility was unable to provide the last two (2) years (2023 and 2022) documentation of sensitivity inspection of the fire alarm system.


43981

Based on observations, the facility failed to protect corridor walls in accordance with NFPA 101 section 19.3.6.1. This deficient practice had potential of affecting the entire facility on the day of facility survey.

Findings include:

On 7/12/23 at 10:55 AM, observation revealed holes and open penetration throughout corridor walls in the facility. The corridor walls were not sealed and were incapable of resisting the passage of smoke throughout the facility. The facility is not protected by fire sprinkler system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.


43981