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Based on visual observation the facility failed to provide hazardous areas that are protected in accordance with 18.3.2.1. Doors shall be self-closing in accordance with &.2.1.8.

Findings:

During facility tour between the hours of 11:00 and 12:00 it was observed that
1/Clean linen door has holes around door knob that needs to be filled.
2/Soiled utility room door is not latching in its frame to provide smoke resistant seal.
3/Oxygen room door needs a door closure for door to be automatic-closing.

Interview with Maintenance revealed the facility was not aware that the doors listed were not in compliance with NFPA 7.2.1.8, not providing protection for the facility.

Based on visual observation the facility failed to provide a remote annunciator in a location readily observed by personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source.

Findings:

During the facility tour, between the hours of 11:00 and 12:00 it was observed that a new generator was installed in August for the facility but no remote annunciator was installed at that time.

Interview with Maintenance revealed the facility was not aware that there was no remote annunciator for the emergency power source in the nurses's station.

Based on visual observation the facility failed to provide records for generator weekly inspections and monthly full load testing in accordance with NFPA 99 and 110. Written records of maintenance and testing are to be maintainedand readily available.

Findings:

During the facility tour and record review, between the hours of 11:00 and 12:00 it was observed that there were no readily available wirtten records for the maintenance of the generator.

Interview with Maintenance revealed the facility was in the process of getting with generator company to obtain records of testing off of a computer program.