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Based upon observation and interview with staff, the facility failed to provide a door with a suitable means for keeping the door closed. 19.3.6.3.6 Findings,

The facility had re-purposed a storage room into a small office opening onto the corridor through the PT Department and had removed the door, leaving the room open to the corridor.

Based upon observation and interview with staff, the facility failed to provide smoke barriers with materials capable of providing at least one hour fire resistance rating in accordance with 8.3. 18.3.7.3 Findings,

The Smoke compartment wall where the new addition meets the existing has penetrations and gaps sealed with foam that is not UL Rated as providing a one hour fire resistance. This condition was originally identified at the time of final construction, but was never corrected.

Based upon observation and interview with staff, the width of corridor serving as exit access failed to be maintained free of all obstructions or impediments. 7.1.10 Findings,

The corridor leading through the former ED has been re-purposed as serving the PT Department and the corridor has not been maintained free and clear of all obstructions and impediments to full instant use in case of fire or other emergency. Various PT equipment is sitting in the corridor, obstructing the path of egress.