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Based on observation and interview the facility did not maintain all corridor walls with a minimum ½-hour fire resistance rating.

Findings include:

During the facility tour on 09/28/2020 from 10:40 AM to 12:30 PM, penetrations were observed, above the drop ceiling in the corridor walls, without a fire rated system in the following locations:

-On the third floor, over the double fire doors, next to the OR Supervisor office.
-On the second floor, over the double fire doors, next to elevator #2.
-On the first floor, in room A103, in the brick wall with the HVAC duct penetrating it.
-On the ground floor, over the door to X-Ray services, across from the generator room.

Interview with Staff (CC), Director of Facilities on 09/28/2020 verified the above noted findings as they were identified.

Based on observation and interview, the facility does not ensure that corridor doors fully close.

Findings include:

During facility tour on 09/29/2020 at 11:00 AM, the following was observed:

- The corridor door, on the ground floor, for the soiled linen room did not fully close and latch on its own.

Interview with Staff (CC), Director of Facilities on 09/29/2020 verified the above noted finding as it was identified.