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Based on observation and interview, the facility failed to maintain 1 of 7 smoke barrier walls to resist the passage of smoke.

Findings:

1. A tour of the facility was conducted on 08/12/25, the following observations were made.

3rd floor smoke wall

a) On the north side of the smoke wall one unsealed penetration associated with gray wires was observed above the smoke doors in the attic.

b) On the south side of the smoke wall a hole was observed above the smoke doors in the attic.

2. The Plant Manager was present when the smoke walls were observed at 11:05 a.m. on 08/12/25, and stated he was not aware of the holes in the smoke barrier walls.

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

Findings:

1. Facility maintenance records were reviewed on 08/12/25 at 1:40 p.m., and no documentation was found to show the facility had conducted routine corridor door inspections.

2. The Plant Manager was interviewed during the record review and stated they had never performed corridor door inspections.