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Based on review of facility documentation, staff interview and confirmation, the facility failed to ensure that fire/smoke dampers were tested in accordance with the National Fire Protection Association 90A, 1999 edition, section 3-4. Potentially all patients, visitors and staff could be affected. The facility had a census of 86 patients at the time of the post survey revisit.

Findings include;

On 07/13/15, at 1:30 P.M., interview was conducted with Staff A regarding maintenance documentation related to fire damper testing. Staff A revealed that fire damper testing had been conducted within the past four years on 418 fire dampers within the facility. Eighty-nine of the 418 fire dampers had a "visual test" conducted. With additions to the building since the 1950's some of the fire dampers were physically inaccessible. The visual inspection was conducted due to construction barriers, that while permitting a visual inspection of the damper, did not permit for functional testing of the damper.

Staff A confirmed that 89 fire dampers that were visually inspected were not tested to determine if they operated correctly.



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