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Based on observation and staff interview, the facility failed to ensure all hazardous areas were separated by smoke resistant partitions in 2 of 11 smoke compartments. This deficient practice could cause smoke and gases to migrate into the corridor affecting approximately 15 occupants in the lower level Med Records wing and Shell Space wing. .

Finding are:
Observation and staff interview on 4-20-2021 at 9:50 and 10:00 AM revealed the following:

1. Lower level Shell Space room had 3 unsealed pipe penetrations in the east fire wall.
2. Lower level Medical Records storage room had 12 unsealed pipe penetrations along the corridor wall.

During an interview on 4-20-2021 at 10:00 AM, Maintenance Staff A confirmed the unsealed penetrations.

Based on observation and staff interview, the facility failed to ensure that fire sprinklers would activate at the designated temperature rating of the fire sprinkler. This deficient practice would delay activation of the sprinkler system allowing fire, smoke and gases to spread affecting approximately 8 occupants in 3 of 11 smoke compartments.

Finding are:
Observation and staff interview on 4-20-2021 at 9:40, 9:45 and 11:15 AM revealed the following:

1. A fire sprinkler was missing an escutcheon in the Lower level Marketing office above the desk.
2. A fire sprinkler was missing an escutcheon in the Lower level Pharmacy room.
3. A 24"x 24" acoustical ceiling tile was missing at the 2nd level North wing Nursing Station.

During interview on 4-20-2021 at 11:15 AM Maintenance Staff A confirmed the fire sprinkler and ceiling tile conditions.

Based on documentation review and staff interview, the facility failed to conduct emergency orientation training under varying conditions. This condition would not provide training to staff on their duties, life safety procedures and the fire protection devices in their assigned areas. The deficient practice would affect fire procedure response for all occupants in all smoke compartments.

Findings are:
Record review on 4-20-21 at 9:20 AM revealed the following:

No fire drills or emergency orientation training was recorded for all 3 shifts during May 2020 and all 3 shifts during the 3rd and 4th quarters of 2020 (July - December).

During an interview on 4-20-2021 at 9:20 AM Maintenance Staff A confirmed no fire drills or emergency orientation training was recorded during those months.

Based on observations and staff interview, the facility failed to ensure electrical junction boxes were equipped with cover plates to protect persons from accidental contact. This deficient practice could cause harm to staff and fire, affecting approximately 1 occupant in 1 of 11 smoke compartments. Facility census was 6 and licensed for 21 at the time of the survey.

Finding are:
Observation and staff interview on 4-20-2021 at 10:05 AM revealed the following:

An open electrical junction box was located on the south wall of the lower level Blue Room.

During an interview on 4-20-2021 at 10:05 AM, Maintenance Staff A confirmed the open junction box.

NFPA 70- 314.28(C) Covers.
All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Based on observation and staff interview, the facility failed to provide a precautionary sign that reads "Caution - Oxygen in Use". This deficient practice failed to warn staff and others of the presence of an oxygen enriched atmosphere, which would affect approximately 3 occupants in 1 of 11 smoke compartments.

Finding are:
Observation and staff interview on 4-20-2021 at 10:25 AM revealed the following:

2 oxygen cylinders where located inside the OR Clean Utility room without precautionary signage on the door.

During interview on 4-20-2021 at 10:25 AM, Maintenance Staff A confirmed the lack of signage.

NFPA 99-11.3.4.1
A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.