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Based on observation and interview, the facility failed to maintain 1 of 2 smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 04/11/2024, and the following observation was made.

a) one unsealed penetration, associated with blue computer wires were observed above the smoke doors by ER #3.

2. The maintenance supervisor was present when the smoke wall was observed on 04/11/2024, and he acknowledged the unsealed penetrations to the smoke wall.

Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.
8.3, 19.3.7.3, 19.3.7.5

Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings:

1. The facility records were reviewed on 04/11/2024 and no documentation was found to show the facility had conducted routine corridor door inspections.

2. The facility maintenance supervisor were interviewed during the record review and he stated they had never performed corridor door inspections.


Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Based on record review, observation, and staff interview, the facility failed to properly maintain and test the generator as required by NFPA 99. In the event of an electrical outage. Findings:

1. During the record review on 04/11/2024 there was no documentation the maintenance supervisor was performing an weekly fluid level check and electrolyte test on the generator.

2. The maintenance supervisor was interviewed on 04/11/2024, and stated he did do weekly test on the generator, but did not have documentation.