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Based on observation and interview, the facility failed to maintain the fire sprinkler system. This deficient practice has the potential to prevent the fire sprinkler system from activation in case of a fire, affecting approximately 2 patients and staff in one of four smoke zones (North Wing). This facility has a capacity of 20 and census of 2 patients at the time of the survey.

Findings are:

On 5/15/2019 at 2:25 P.M., observations revealed that the facility failed to provide the required 18 inch clearance between storage on a shelf and the fire sprinkler in the House Keeping Store Room.

During an interview conducted on 5/15/2019 at 2:25 P.M., Maintenance personnel stated that they were unaware of the items stored within the required clearance to the fire sprinkler.