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Based on observation and interview, the facility failed to provide a one-hour fire rated separation at a hazardous area. This deficient practice would allow for fire and smoke to extend beyond the hazardous area into the adjacent larger storage area. This deficient practice would affect approximately 3 occupants working in the area and the Dialysis area located across the corridor from the IT room #173. There were 4 patients located on the hospital's main floor at the time of the LSC survey

Findings are:
Observation on 08-19-20 at 11:15 AM. revealed, a void space was located in the west wall surrounding an electrical conduit in IT Room #173.

In an interview with Maintenance Personnel on 08-19-20 at 12:00 PM the findings were verified as to the void space within the IT Room #173.

Note K919
Based on observation and interview the facility failed to provide separation at electrical components in the northeast basement storage room. This deficient practice would allow for a fire to spread within this storage room and would affect all staff working in the basement office areas, and would not allow for the safe use of the stairway for access to an exit leading from the basement. There were 5 patients within the facility at the time of the LSC survey. Facility is licensed for 25 patients.


Findings are:
Observation on 08-19-20 at 11:45 AM revealed combustible material located within three feet of a electrical transformer, and electrical panel boxes located in the record storage room. This room is adjacent to the northeast exiting stairway leading to the outside of the building.

In an interview on 08-19-20 at 12:00 PM Maintenance Personnel 1 confirmed the findings.