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Tag No.: K0131
Based on observation and interview, the provider failed to maintain the fire-resistive design of one of two building separation walls (between the hospital and the clinic). Findings include:
1. Observation on 8/30/22 at 8:30 a.m. revealed the two-hour fire-rated separation wall between the hospital and the clinic had unsealed penetration openings in the wall above the lay-in ceiling.
*The wall above the lay-in ceiling at the alternate swing ninety-minute fire-rated doors had two unsealed conduit penetrations.
*The wall above the lay-in ceiling at the staff clinic ninety-minute fire-rated door had three unsealed penetration openings approximately two inches by three inches for category 5 computer cable.
The penetrations of the gypsum board layers at those locations were not sealed with an approved firestop material to maintain the fire rating of the wall.
Interview with the director of plant operations at the time of the observations confirmed those findings.
The deficiency could affect 100% of the occupants of the smoke compartment.
Tag No.: K0351
Based on observation and interview, the provider failed to maintain unobstructed space adjacent to the sprinkler deflector so the water discharge was not interrupted in one randomly observed location (temporary central supply location). Findings Include:
1. Observation on 8/30/22 revealed two sprinklers installed in the temporary central storage location (former CT room) which contained metal racks and storage of boxed supply items. The sprinkler in the center of the room above the center rack had boxes stacked to within approximately eight inches of the bottom of the sprinkler. The minimum clearance below a sprinkler is required to be eighteen inches.
Interview with the director of plant operations at the time of the observation confirmed that finding. He stated he was unaware of the storage items stacked so they obstructed the sprinkler discharge.
The deficiency affected one location required to be equipped with unobstructed fire sprinkler protection.
Ref: 2012 NFPA 101 Section 19.3.5.1, 9.7.1
Tag No.: K0911
Based on observation and interview, the provider failed to maintain the required clearance for one randomly observed piece of electrical equipment (main automatic transfer switch) in the electrical room. Findings include:
1. Observation on 8/30/22 at 9:35 a.m. revealed the electrical room had three powered floor cleaning equipment items (scrubbers and polishers) stored in front of the switches. There was approximately 10 inches of clearance between the switches and the floor maintenance equipment. The minimum clearance requirement for the electrical switches must be maintained at 36 inches.
Interview with the director of plant operations at the time of the observation confirmed that finding.
The deficiency affected one of numerous requirements for the maintenance of electrical equipment.