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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, 8.6.7.1(1). These deficient practices have the potential of affecting two (2) of four (4) smoke compartments in the facility on the day of survey.

Finding includes:

On 1-19-17 at 10:45 AM, observations revealed open and unsealed penetrations in the smoke barrier walls in the following areas of the facility:

1. The smoke barrier wall near the Center Core
2. The smoke barrier wall near the ICU (Intensive Care Unit)

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

Based on observations the facility failed to provide the required weekly inspection of generator in accordance to NFPA 110 section 8.4.1. This deficient practice had the potential of affecting the entire facility on the day of survey.
Finding includes:
While reviewing documentation on 1-19-17 at 11:50 AM, the facility failed to provide the documentation for weekly inspection of the generator in the facility.
The administrator and maintenance director were notified during the survey and in the exit conference.