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Based on observation and staff interview, the facility failed to maintain smoke resistant ceiling in a manner that would retard the spread of smoke to adjacent areas in the event of fire. Findings:

1. During a tour of the facility on 08/30/2023, the following observation was made:

a. The ceiling of the inside mechanical room/laundry room near the Womens hall, containing gas-fired water heater, was noted to have unsealed penetrations around vent pipe and the door did not have a self closing device. This room opened onto a exit corridor.

2. The maintenance supervisor was present during the entire tour of the facility on 08/30/2023 and acknowledged the unsealed penetration and the door not having a self closing device.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one hour fire resistance rating or provided with an automatic sprinkler system, doors shall have closer and positive latches. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. NFPA 101, 19.3.2.1

Based on record review and interview, the facility failed to ensure the semi-annual kitchen hood inspections were performed. Findings:

1. The facility records were reviewed on 08/23/2023 at 2:10 p.m. The most recent annual kitchen hood inspection report was dated January 2023. The next kitchen hood inspection should have been performed on or before July 2023. No documentation was found to show a current kitchen hood inspection had been performed.

2. The maintenance supervisor was interviewed on 08/23/2023 at 2:10 p.m., and he stated they are in contract negotiations.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system.

1. The facility records were reviewed on 08/30/2023 at 2:10 p.m. The most recent annual sprinkler inspection document was dated 08/23/23. The next annual sprinkler inspection should have been performed on or before 08/23/23. No documentation was found to show a current annual sprinkler inspection had been performed.

2. The maintenance supervisor was present during the record review on 08/23/2023 and stated the company and the facility are in contract negotiations so the annual has not been completed.

Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

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

1. A tour of the facility was conducted on 08/30/23, and the following observations were made.

Acute Care Unit smoke walls

a) one unsealed penetration, associated with a open pipe chase was observed above the exit door just before the Womens hall.

b.) Three unsealed penetrations associated with the electrical conduit for the magnetic hold opening devices for the men's sleeping rooms.

2. The maintenance person was present when the smoke walls were observed on 08/30/23, and he acknowledged the unsealed penetrations to the smoke wall.

Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.
8.3, 19.3.7.3, 19.3.7.5