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Based on observation and staff interview, the facility failed to ensure a set of doors in a horizontal exit would resist the spread of fire. This condition would allow the spread of fire between 2-hour separated areas of the facility.

Findings are:
Observation on 8/22/19, at 11:09 am revealed the 90-minute fire rated Double Doors 225 and 226 in the horizontal exit did not positively latch when self-closed.

In an interview on 8/22/19, at 11:09 am, Maintenance A confirmed the doors did not positively latch.

Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors. This condition would allow smoke to enter the egress corridor.

Findings are:
Observation on 8/22/19, from 10:57 am to 11:48 am revealed:
1. The Linen Closet Storage Room Door did not positively latch when self-closed.
2. The Elevator Equipment Room Door did not positively latch when self-closed.
3. The Film Storage Room Door did not positively latch when self-closed.
4. OR Clean Closet Doors did not positively latch when self-closed.

In an interview on 8/22/19, from 10:57 am to 11:48 am, Maintenance A acknowledged the doors did not positively latch.

Based on observation and staff interview, the facility failed to use electrical wiring in a way that would not create a fire hazard. This condition had the potential to cause a fire.

Findings are:
Observation on 8/22/19, at 11:26 am revealed exposed electrical wiring was not installed in a junction box with a cover above the south interior door in the Main Electrical Room.

In an interview on 8/22/19, at 11:26 am, Maintenance A acknowledged the lack of junction box cover.

NFPA 70, 2011, 322.56 Splices and Taps.
(A) Splices. Splices shall be made in listed junction boxes.