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The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and fire-rated door assemblies. Two (2) of six (6) hazardous areas were not separated from other areas with UL rated fire-rated door assemblies.

Door manufacturers typically are required to install an intumescent gasket and a fire rated smoke gasket between wood doors and the metal door frame to achieve a 45, 60, or 90 minute fire rating.

1) Observation determined the Medical Records Storage Room corridor door was a 90-minute rated fire door and was not equipped with an intumescent gasket or a fire rated smoke gasket.

2) Observation determined the 60-minute fire rated door between the Medical Records Storage Room and Housekeeping Storage Room was not equipped with an intumescent gasket or a fire rated smoke gasket.

3) Observation determined the 60-minute fire rated corridor door at Housekeeping Storage was not equipped with an intumescent gasket or a fire rated smoke gasket.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system and the sprinklers were maintained in operable condition.

Observation determined the cabinet for extra sprinkilers did not contain intermediate temperature rated sprinkler (green glass bulb color) for replacement of the sprinklers located above the boilers located in the Boiler Room.

The facility failed to ensure electrical wiring and electrical equipment meet NFPA 70 requirements.

Observation determined there was an electrical power strip mounted at the bed headboard area of the four Intensive Care Unit Rooms.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and fire-rated door assemblies. Two (2) of six (6) hazardous areas were not separated from other areas with UL rated fire-rated door assemblies.

Door manufacturers typically are required to install an intumescent gasket and a fire rated smoke gasket between wood doors and the metal door frame to achieve a 45, 60, or 90 minute fire rating.

1) Observation determined the Medical Records Storage Room corridor door was a 90-minute rated fire door and was not equipped with an intumescent gasket or a fire rated smoke gasket.

2) Observation determined the 60-minute fire rated door between the Medical Records Storage Room and Housekeeping Storage Room was not equipped with an intumescent gasket or a fire rated smoke gasket.

3) Observation determined the 60-minute fire rated corridor door at Housekeeping Storage was not equipped with an intumescent gasket or a fire rated smoke gasket.

The facility failed to ensure all areas were protected by the automatic fire sprinkler system and the sprinklers were maintained in operable condition.

Observation determined the cabinet for extra sprinkilers did not contain intermediate temperature rated sprinkler (green glass bulb color) for replacement of the sprinklers located above the boilers located in the Boiler Room.

The facility failed to ensure electrical wiring and electrical equipment meet NFPA 70 requirements.

Observation determined there was an electrical power strip mounted at the bed headboard area of the four Intensive Care Unit Rooms.