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Based on observation and staff interview, the facility failed to maintain smoke resistant ceiling, walls and self closing devices in a manner that would retard the spread of smoke to adjacent areas in the event of fire. Findings:

1. During a tour of the facility on 01/03/2024, the following observations were made:

a. The wall of the inside mechanical room in the front of the building by the kitchen, containing gas-fired furnaces and/or gas-fired water heaters, was noted to have unsealed penetrations around computer wires exposing the adjacent space to the hazardous areas.

b. The ceiling of the inside mechanical room in the back of the facility by the dining room, containing gas-fired furnaces and/or gas-fired water heaters, was noted to have unsealed penetrations around vent pipe and water lines exposing the attic space to the hazardous area. The double doors to this mechanical room had a gap between the doors that would not resist the passage of smoke.

2. The Director of Plant Operations was present during the entire tour of the facility on 01/03/2024 and acknowledged the unsealed penetration and the gap between the doors.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one hour fire resistance rating or provided with an automatic sprinkler system, doors shall have closer and positive latches. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. NFPA 101, 19.3.2.1

Based on record review and interview, the facility failed to ensure the semi-annual kitchen hood inspections were performed. Findings:

1. The facility records were reviewed on 01/03/2024 at 9:20 a.m. The most recent annual kitchen hood inspection report was dated 03/28/2023. The next kitchen hood inspection should have been performed on or before 09/28/2023. No documentation was found to show a current kitchen hood inspection had been performed.

2. The Director of Plant Operations was interviewed on 01/03/2024 at 9:40 a.m., and he stated he could not find documentation the inspection had been performed.

Based on observation and interview, the facility failed to maintain 2 of 2 smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 01/03/24, and the following observations were made.

Both smoke walls

a) Unsealed penetrations in both smoke barrier walls associated with computer wires and black wires was observed above the smoke doors in the attic.

2. The Director of Plant Operations was present when the smoke walls were observed on 01/03/24, and he acknowledged the unsealed penetrations to the smoke walls.