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Based on observations, the facility failed to assure the integrity of all fire/smoke rated walls and properly identify all rated walls, as required:

NFPA 101: 8.3.5.1 ..... Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

Observation revealed holes and unsealed penetrations in the rated walls of the Mechanical Room and Oxygen Storage.

In an interview, the Maintenance Director stated that the holes will be properly sealed and all rated walls will be properly identified.

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Based on observation, the facility failed to indicate the circuit breaker that provides power on the Fire Alarm system on the Fire Alarm Control Panel (FACP) and at the Electrical Panel. This circuit breaker shall be marked with a red color within the panel, as required by:

NFPA 99: 4.4.2.2.2.2. It is presently connected to the normal power serving the building. There shall be a label provided on the face of the panel that indicates the panel name and circuit number that provides power to the FACP

NFPA 72: 1-5.2.5.2

Please provide and install signage and labels.

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Based on observation, the facility failed to provide a complete functioning plumbing system due to a water closet not flushing, as all piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code published by the National Association of Plumbing-Heating-Cooling Contractors.

Please repair all water closets that are not flushing.

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Based on observation, the facility failed provide operating exhausts at all restrooms. Please verify all restroom exhaust fans are operational.

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Based on document review, the facility failed to provide the performed fire drills for the last three months.

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