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Based on observation and staff interview, the facility failed to maintain smoke resistant ceiling 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 06/21/2023, the following observations were made:

a. The ceiling of both outside mechanical rooms on the northwest side of the building, 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 areas.

2. The plant supervisor was present during the entire tour of the facility on 06/21/2023 and acknowledged the unsealed penetration.

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 staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings:

1. The facility records were reviewed on 06/21/2023. The most recent annual sprinkler inspection document was dated 02/03/2023. The facility could not provide documentation they had performed quarterly sprinkler inspection for the past year.

2. The Plant supervisor was present during the record review and stated the quarterly sprinkler inspections had not been done.

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

1. A tour of the facility was conducted on 06/21/23, and the following observation was made.

Fire wall between the Hospital and the Clinic

a) Two unsealed penetration, associated with blue computer wires was observed above the fire doors.

2. The Plant supervisor was present when the fire wall was observed on 06/21/23, and he acknowledged the unsealed penetrations to the fire wall.

Based on record review and staff interview, the facility failed to assure the minimum required number of fire drills were conducted within the past year. Findings:

1. Review of the facility fire drill reports was conducted on 06/21/2023. There was no documentation the facility had conducted a fire drill for the following shift:

a. the first, second shifts for the third quarter of 2022.

b. the first shift for the fourth quarter of 2022.

2. The plant supervisor was interviewed on 06/21/2023, and stated the facility missed the fire drill for those shifts.