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Based on observations, the facility failed to protect Hazardous area in accordance to NFPA 101 section 19.3.2.1. This deficiency affected the entire facility on day of survey.

Findings Include:

On 10/14/2021 at 9:30 AM, observation revealed the following rooms were incapable of resisting the passage of smoke throughout the facility:

1. West Wing Laundry Room, an unsealed hole around electrical piping and dryer vent through the ceiling.

2. Mechanical Room near Radiology contain unsealed holes around electrical piping and data cables through ceiling.

3. Mechanical Room near Cafeteria contain unsealed holes around electrical piping through ceiling.

4. Mechanical Room/Boiler Room contain unsealed holes around water piping through wall.

5. Soiled Linen Room, near Boiler/Mechanical Room contain unsealed hole around sprinkler piping through ceiling.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 10/14/2021.