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Based on observation and interview, the facility failed to maintain fire resistive construction for a hazardous area. This deficient practice has the potential of affecting approximately 6 occupants in one of ten smoke zones and has the potential to allow fire and smoke to spread beyond the storage room. This facility has a capacity of 25 and census of 6 patients at the time of the survey.

Findings are:

On 1/25/2024 at 11:50 A.M., observations revealed that the facility failed to provide construction that would resist the passage of smoke by not sealing penetrations in the Bio Room. Two electrical conduits did not have any sealant and one conduit had the sealant that had not been maintained.

During interview conducted on 1/25/2024 at 11:50 A.M., Maintenance personnel stated that they were unaware that penetrations at the Bio Room had not been sealed.