HospitalInspections.org

Based on observations, the facility failed to properly protect corridors in accordance to NFPA 101 sections 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5. These condition deficiencies affected the entire facility on day of survey.


Findings include:

On 07/27/16 between 10:00 AM and 11:00 AM, observation revealed the corridor walls had numerous unsealed penetrations above the suspended ceiling in the Central and West Wings of the facility. It was also observed the one hour rated solid ceiling above the corridor walls of the Central and West Wings were damaged, contain open penetrations, and partial removed. This facility was not protected by automatic fire sprinkler system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 07/27/16.

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.