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Based on observation, review of National Fire Protection Association (NFPA) guidelines and interview, it was determined the facility failed to prevent the likelihood of the spread of fire and smoke in the respiratory storage closet in that was a hole in fire wall with wires passing through. The failed practice placed patients at risk of fire and/or smoke spreading. The failed practice had the likelihood to affect all patients in the facility. The findings will follow:

A. Review of the NFPA 101 guidelines showed, "Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke."
B. On March 11, 2024, at 11:18 a.m., observation showed the respiratory storage closet had a hole in the fire wall with cables passing through the hole. There was no material protecting the hole to prevent fire and/or smoke passing through the hole.
C. The findings of B were confirmed in an interview with the Administrator on March 11, 2024 at 11:18 a.m.