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Tag No.: K0362
Based on observation and interview, the facility did not provide 1-hour fire rated corridor wall separations as required in NFPA 101, 2012 edition, Sections 19.3.6.2.1, 8.4.2, 8.2.3, 8.2.3.1, 8.2.3.1.1, 8.3.5 and 8.3.5.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.
Findings include:
On 12/06/2023 at 12:16 PM, observation in the corridor on the east side of the lab between the lab and the boiler room revealed a corridor wall that was not constructed to a 1-hour fire rating as indicated by the "1-HR FIRE" stenciling on the wall. There were 2: one foot X one foot scab drywall patches on either side of an I beam which penetrated the wall on an angle and 2: two-foot X one-foot purple faced drywall scab patches. Scab patches do not provide protection in accordance with the listed penetration firestop assembly Gypsum Association GA-225-2019.
This deficient practice was confirmed by Staff A and B at the time of discovery.