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Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 4 residents, staff and visitors in this smoke compartment. The facility has a capacity of 16 and a census of 4.

Findings include:

Observation and interview on 05/30/2013 at 12:01 p.m., revealed the facility failed to maintain the Fire Alarm System in the Operating Room corridor. This corridor contained a smoke detector with in three feet of an air diffuser near Room #14. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 16 and a census of 4.

Findings include:

Observation and interview on 05/30/2013 at 11:30 a.m., revealed the facility failed to maintain the sprinkler system in Lab Storage Room #402-A. This room contained a cardboard box stored directly under the sprinkler. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing all Staff in this room at risk in the event of a fire. The facility had a capacity of 16 and a census of 4.

Findings Include:

Observation and interview on 5/30/2013 at 11:45 a.m., revealed the facility failed to maintain the electrical system in the Mechanical Room #514. This room contained old temporary wiring with exposed wires along the ceiling. The Maintenance Director verified this observation at the time of the survey process.