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Doors protecting corridor openings are constructed of 1 3/4 inch solid-bonded core wood, and capable of resisting fire for at least 20 minutes. Doors to resist passage of smoke and shall be provided with means suitable for keeping the door closed.

Based on visual observation between the hours of 11:00 and 1:00 it was observed that 8 out of the 10 patient rooms on the Behavioral Health Unit has holes in the doors where door handles where changed out to new ones. The holes need to be sealed to resist passage of smoke.

Interview with the Maintenance Supervisor stated that she was not aware that these doors where not sealed in order to resist the passage of smoke.

Hazardous areas to be one hour fire rated construction or if facility is sprinklered these areas shall be separated from other spaces by smoke reisting partitions and doors. Doors shall be self-closing .

Based on visual observation between the hours of 11:00 and 1:00 it was observed that in Purchasing/Central Supply room there were several penetrations and holes in the walls that adjoin the corridor that need to be sealed.

Interview with Maintenance Supervisor revealed that she was not aware that there were holes in the rated wall that needed to be sealed.