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The facility failed to maintain the corridor walls in non sprinklered sections of a facility per code. Findings include:

During the revisit, the following are examples of what was observed:

Second Floor
3. The right side corridor wall (the Pharmacy side) did not extend to the deck above, an HVAC duct runs between the corridor wall and the deck above. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)

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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the revisit, the following are examples of what was observed:

Second Floor
1. The Stock Room was approximately 144 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)
2. Housekeeping was approximately 168 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room. (Per maintenance staff the old plaster ceiling was removed during the renovation of the I.C.U on the third floor - after last survey)
First Floor
3. Dietary Storage was approximately 192 sq. ft. with combustibles -
a. The walls did not extend to the deck above nor was there a one hour rated ceiling in this room.

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to maintain the anesthetizing locations per code. Findings include:

During the revisit, the following is an example of what was observed:

Per maintenance staff the facility has been incontact with ADPH's Plan Review Department.

Per administrative and maintenance staff the three second floor windowless ORs did not have a smoke venting system. This addition was done in 1995.
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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
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