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Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located in 2 of 5 smoke compartments. Findings:

1. A tour of the facility was conducted on 04/11/25., and the following observations were made:

a. The CT scan room door had old hardware that had been removed leaving two hole in the door for smoke to pass through.

b. The quality improvement office door had old hardware that had been removed leaving two hole in the door for smoke to pass through.

c. The respiratory therapy office door had old hardware that had been removed leaving two hole in the door for smoke to pass through.

2. The maintenance person was present during the tour of the facility and acknowledged the holes in the doors.

Based on observation and interview, the facility failed to maintain 3 of 7 smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 04/11/25, and the following observations were made.

a) The smoke barrier wall by the ER had unsealed penetration associated with fiber optic wires that were observed above the smoke doors.

b.) The smoke barrier wall by patient room #101 had unsealed penetration associated with electrical conduit that was observed above the smoke doors.

c.) The smoke barrier wall located by the sleep lab had unsealed penetration associated with computer wires that was observed above the smoke doors.

2. The maintenance person was present when the smoke walls were observed on 04/11/25, and he acknowledged the unsealed penetrations to the smoke wall.