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Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located in 1 of 4 smoke compartments. Findings:

1. A tour of the facility was conducted on 11/15/23., and the following observation was made:

a. The door to the patient supply closet had two holes where old hardware had been removed. This door would not resist the passage of smoke.

2. The maintenance supervisor was present during the tour of the facility and acknowledged the holes in the doors.

Based on observation and interview, the facility failed to maintain 3 of 4 smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 11/14/23, and the following observations were made.

East, West and North wings smoke wall

a) One unsealed penetration, associated with each smoke wall. A pipe chase for wires was ran through the smoke wall. Several types of wire were running through the pipe. Both ends of the pipe were open that would allow smoke to pass through.

2. The maintenance person was present when the smoke walls were observed on 11/14/23, and he acknowledged the unsealed penetrations to the smoke wall.