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Based on observation and staff interview, the facility does not ensure that the smoke resistive barriers and one-hour fire resistant barriers are maintained.

Findings Include:

Observations on 02/04/24 at 11:55 AM in the power room on the ground floor, above the door, revealed two approximately one inch holes with information technology and fire alarm wire penetrating the wall without a smoke resistant system in place to seal around the wires.

Interview on 02/04/24 with Staff (Z), Director of Facilities, verified this finding as observed.

Observations on 02/05/24 during a tour of the facility with Staff (AA), Maintenance Mechanic, and Staff (BB), Maintenance Helper revealed the following penetrations in the smoke and fire resistant barriers:

-At 9:25 AM in the maintenance room, above the door to the boiler room, an approximately ½-inch pipe penetrating the wall without a smoke resistant system in place to seal around the pipe.
-At 9:30 AM in the boiler room, above the condensate tank, two approximately 5-inch pipes penetrating the wall without a smoke resistant system in place to seal around the pipes.
-At 9:32 AM in the boiler room, above the door to the corridor, an approximately 4-inch by 12-inch hole penetrating the ceiling without a smoke resistant system in place to seal the hole.
-At 10:30 AM in the mechanical room on the first floor for air handler number two, above the door, an approximately 12-inch by 12-inch hole for copper pipes penetrating the wall without a smoke resistant system in place to seal around the pipes.
-At 10:43 AM in the soiled utility room next to the medical rehab unit, a penetration in the drywalled ceiling which was previously patched with an approximately 24-inch by 36-inch piece of drywall that was sagging and falling away resulting in a penetration without a smoke resistant system in place.
-At 11:30 AM in the mechanical room on the second floor, on the east wall, two approximately 2-inch pipes penetrating the wall without a smoke resistant system in place to seal around the pipes.
-At 11:50 AM in the mechanical room on the third floor, on the south wall, two approximately 2½-inch steam pipes penetrating the wall without a one hour fire resistant system in place to seal around the pipes.
-At 11:55 AM in the mechanical room on the third floor, on the north wall, an approximately 2-inch electrical conduit penetrating the wall without a one hour fire resistant system in place to seal around the conduit.

Interview on 02/06/24 at 1:00 PM with Staff (Z), Director of Facilities, verified these findings.

Based on observation and staff interview, the facility does not ensure that the smoke barriers 1/2-hour fire resistance rating is maintained.

Findings Include:

Observations on 02/05/24 during a tour of the facility with Staff (AA), Maintenance Mechanic, and Staff (BB), Maintenance Helper revealed the following penetrations in the smoke barrier walls:

-At 9:50 AM in the corridor on the back side of the cafeteria, over the door above the drop ceiling, an approximately 4-inch hole with a paper towel stuffed in it without a ½-hour fire resistant smoke barrier system in place.
-At 11:00 AM in the corridor near board room B door, above the drop ceiling, an approximately 1-inch hole with an electrical conduit penetrating the wall without a ½-hour fire resistant smoke barrier system in place.
-At 11:05 AM in board room B near the corridor door, above the drop ceiling, an approximately 4-inch by 18-inch hole in the wall without a ½-hour fire resistant smoke barrier system in place.

Interview on 02/06/24 at 1:00 PM with Staff (Z), Director of Facilities, verified these findings.