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Based on observation and interview, the facility failed to maintain a directional exit sign at the end of the corridor for one of six exits. This deficient practice affects approximately 5 residents, staff and visitors in the X-Ray Department. The facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 9/24/2019 at 12:38 p.m., revealed the facility failed to maintain a directional exit sign in the X-Ray Department near the Southwest exit door. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. 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 2011 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 25 and a census of 5.

Findings include:

Observation and interview on 9/24/2019 at 1:30 p.m., revealed the facility failed to maintain the sprinkler system in the Basement Bio-Hazard Storage Room. This room contained white and orange wires zip tied to sprinkler pipe. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of ten smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 5 residents, staff, and visitors in the Dietary Area. The facility has a capacity of 25 with a census of 5.

Findings include:

Observation and interview on 9/24/2019 at 1:00 p.m., revealed the Dietary Smoke Barrier contained a one half inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. 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, 2011 edition, affecting one staff in this room. The facility had a capacity of 25 and a census of 5.

Findings Include:

1. Observation and interview on 9/24/2019 at 12:20 p.m., revealed the facility failed to maintain the electrical system in the 2-North Nurse Station. This room contained two standard outlets near the sink that were not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 9/24/2019 at 12:30 p.m., revealed the facility failed to maintain the electrical system in the X-Ray Exam Room #2. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.