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Based on observation and interview, the facility failed to maintain the required one-hour fire resistive construction for hazard areas. This deficient practice could cause smoke and hot gases to migrate into the corridor. The deficient practice could affect approximately 1 occupant in 1 of 5 smoke compartments (Facilities & Maintenance). The facility census was 4.

Findings are:

Observations on 6-6-2023 at 10:24 AM revealed the following:

1) The boiler room had a piece of threaded rod coming from the ceiling that ran along the separation wall leaving a gap in the separation wall that was unsealed.

During an interview on 6-6-2023 at 10:24 AM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to provide documentation for the fire alarm system smoke detector sensitivity testing. This deficient practice did not ensure that all fire alarm devices were inspected and increased the potential that the fire alarm would fail to operate during a fire. The deficient practice affected all occupants. The facility census was 4.

Findings are:

Record review on 6-6-2023 at 10:02 AM revealed the following:

1) The facility failed to provide documentation that the facility's fire alarm system had sensitivity testing completed for the system smoke detectors for the past 24 months.

During an interview on 6-6-2023 at 10:02 AM, Maintenance Staff confirmed the finding.

Based on observation and staff interview, the facility failed to provide a complete ceiling assembly in 1 of 5 smoke compartments (Emergency) by allowing ceiling tiles to be present with approximate 2-inch by 4-inch holes in them. This deficient practice did not ensure smoke and gases would be kept below the ceiling to activate the fire sprinkler system and/or the fire alarm system and would cause these systems to fail to operate as designed affecting all building occupants.

Findings are:

Observations on 6-6-2023 at 10:39 AM revealed the following:

Facility failed to maintain the drop-tile ceiling in the Emergency Department by allowing a ceiling tile near the north entry doors to have a hole in the center allowing smoke and hot gases to penetrate above the ceiling.

During an interview on 6-6-2023 at 10:39 AM, Maintenance Staff confirmed the finding.