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Based on observation and interview, the facility failed to maintain the minimum required clearance for fire sprinklers in 1 of 5 smoke compartments (Basement West). The deficient practice would cause an obstruction to the water spray in the event of a fire, and failure of fire sprinklers to operate as designed. The deficient practice would affect approximately 1 occupant. The facility census was 3.

Findings are:

Observations on 4-17-2019 at 11:33 AM revealed the following:

1) The facility allowed a cabinet to be within 18-inches of the fire sprinkler deflector in the basement Records Room.

During an interview on 4-17-2019 at 11:33 AM, Maintenance Staff confirmed the finding.

Based on observation and staff interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke in 1 of 5 smoke compartments (2nd Floor East). This deficient practice could cause smoke and gases to migrate into the exit corridors affecting approximately 1 occupant. The facility census was 3.

Findings are:

Observations on 4-18-2019 at 12:00 PM revealed the following:

1) Physical Therapy South Room corridor door did not seal within the doorframe.

During an interview on 4-17-2019 at 12:00 PM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to conduct fire drills under varied conditions and varied times on 2 of 2 shifts. This deficient practice would not simulate an emergency response during varied staffing levels. This would affect all occupants. Facility census was 3.

Findings are:

Record review on 4-17-2019 at 10:39 AM revealed the following:

1) Facility conducted four of four drills on 1st shift at: 10:30 AM, 9:45 AM, 9:15 AM, and 3:00 PM.
2) Facility conducted four of four drills on 2nd shift at: 8:00 PM, 5:15 PM, 5:00 PM, and 4:45 PM.

During an interview on 4-17-2019 at 10:39 AM, Maintenance Staff confirmed the findings.

Based on observation and staff interview the facility failed to provide approved cover plates for electrical receptacles and junction boxes. This deficient practice increased the potential of an electrocution injury or fire from unintended contact with live electrical equipment. The deficient practice affected approximately 1 occupant. The facility census was 3.

Findings are:

Observations on 4-17-2019 at 11:40 AM revealed a junction box missing cover the plate in the Boiler Room.

During an interview on 4-17-2019 at 11:40 AM, Maintenance Staff confirmed the finding.