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Based on observation during facility tour and staff interview it was determined the facility failed to ensure the sprinkler system, more specifically, sprinkler pendent were not impeded from there normal operation during activation of the suppression system according to the National Fire Protection Association (NFPA) 13, Chapter 5. This had the potential to affect all patients utilizing this facility. The facility census at the time of the survey was 97.

Findings include:

Facility tour took place on 08/30/16 at 1:22 PM with staff members A, B, C, D, E, F, G and I. During tour of the boiler room there were many insulated and non-insulated steam lines traversing both horizontally and vertically. Observation was made of a thick insulated "blanket" placed over the top of a group of steam pipes within inches below the sprinkler line. This covering or "blanket" had the potential to adversely affect the spray pattern of the sprinkler pendants had they been activated in the event of a fire. This finding was acknowledged by staff members D and I during tour of the boiler room.