HospitalInspections.org

This Standard is not met as evidenced by:

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. These deficient practices have the potential of affecting 3 of 3 smoke compartments. This condition has the potential to affect 14 of 14 residents in the facility at the day/time of survey.

Finding include:

While inspecting smoke barrier walls on October 27, 2015 at 10:30 a.m., observations revealed these smoke barrier walls had the following unsealed penetrations in the following area:

1. Smoke barrier wall located near Patient Room #1 had open and unsealed penetrations above ceiling.

2. Smoke barrier wall located near Patient Room #17 did not extend to at deck above.

3. Smoke barrier wall located near Patient Room #9 has unsealed penetrations passing through barrier wall above ceiling.

The administrator and maintenance director were notified during the survey and in the exit conference on October 27, 2015.