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Based on observations, the facility failed to maintain the fire rated construction of the 1-hour ceiling assembly. The building construction is NFPA type V (111).

The findings include:

1. Observation on 08/12/2025 at 11:32 AM, revealed unsealed penetrations by electrical and HVAC lineset items in the 1-hour fire rated ceiling of the kitchen storage room. NFPA 101, 8.3.5.1 (2012 Edition)

2. Observation on 08/12/2025 at 11:51 AM, revealed an unsealed penetration by low voltage wiring in the 1-hour fire rated ceiling of the IT room. NFPA 101, 8.3.5.1 (2012 Edition)

3. Observation on 08/12/2025 at 12:10 PM, revealed an unsealed penetration by low voltage wiring in the 1-hour fire rated ceiling of the 100 hall Electrical room. NFPA 101, 8.3.5.1 (2012 Edition)

The Maintenance Director was present when these findings were identified and they were acknowledged by the Administrator during the exit conference on 08/12/2025.

Based on document review and interview, the facility failed to maintain the emergency lighting.

The finding includes:

Document review on 08/12/2025 at 10:50 AM, revealed the facility could not provide monthly or annual testing documentation for the battery backup emergency lights. Interview with the Maintenance Director revealed the facility did not keep logs documenting lighting tests. NFPA 101, 19.2.9.1 (2012 Edition) NFPA 101, 7.9.3.1.1 (2012 Edition)

The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.

Based on document review, the facility failed to maintain the fire alarm system.

The finding includes:

Document review on 08/12/2025 at 10:30 AM, revealed the facility could not provide documentation for the required 2 year smoke detector sensitivity testing. NFPA 101, 19.3.4.1 (2012 Edition) NFPA 101, 9.6.1.3 (2012 Edition) NFPA 72, 14.4.5.3.2 (2010 Edition)

The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.

Based on observations and interview, the facility failed to maintain the HVAC systems.

The findings include:

Observations on 08/12/2025 at 11:42 AM, revealed 3 ceiling HVAC openings connected above the ceiling with flexible duct that were not equipped with fire dampers in the 1 hour fire rated ceiling at the 200 hall nurses station and medication room. Interview with the Maintenance Director revealed this space had been renovated in 2024 and the ductwork added for these rooms. NFPA 101, 19.5.2.1 (2012 Edition) NFPA 101, 9.2.1 (2012 Edition) NFPA 90A, 5.3.1.2 (2012 Edition)

The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.

Based on document review and interview, the facility failed to maintain the emergency backup generator.

The finding includes:

Document review on 08/12/2025 at 10:15 AM, revealed the facility could not provide annual fuel quality testing documentation for 2023 or 2024. Interview with the Maintenance Director revealed this test had not been conducted prior to this year, but was now part of the contract. NFPA 99, 6.4.4.1.1.3 (2012 Edition) NFPA 110, 8.3.8 (2010 Edition)

The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.