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Based on observation and interview, the facility is not ensuring that doors to resident rooms are free of impediments that would prevent the door from closing tightly into the door frame. This deficient practice affects all occupants in one of eight smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 6 residents.

Findings include:

Observation and interview on 9-6-16 at approximately 10:25 a.m., revealed that the resident room door of room #A 105 contained a 1/4 of an inch gap at handle side of the door. The resident room door contained a side leaf for Geriatric use and did not have a door frame on the handle side.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility did not provide a directional exit signs at the end of a resident corridor for one of eight smoke compartments. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 6 residents.

Findings include:

Observation and interview on 9-6-16 at 10:45 a.m., revealed the exit sign located on the east end of the Entrance 3 corridor was obstructed by a ceiling header.

According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff (A) verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 6 residents.

Findings include:

Observations and interview on 9-6-16, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the Surgery Parts Washer room.
2. Smoke detector next to air diffuser in the Dining room next to the south wall.

Maintenance Staff (A) verified these observations.

Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that Main Sprinkler Riser gauges are calibrated. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 6.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

Observation and interview on 9-6-16 at approximately 11:00 a.m., showed Sprinkler Riser located in the Emergency Preparedness Storage and the Out Side Riser room contained gauges dated 2009. Gauges need to be replaced or recalculated every 5 years.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of four smoke zones. The facility had a capacity of 25 and a census of 6 at the time of survey.

Findings include:

Observation and interview on 9-6-16 at approximately 11:37 a.m., revealed that in the Kitchen over the food preparation area the sprinkler head bulb was covered with dust.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not ensuring that doors to resident rooms are free of impediments that would prevent the door from closing tightly into the door frame. This deficient practice affects all occupants in one of eight smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 6 residents.

Findings include:

Observation and interview on 9-6-16 at approximately 10:25 a.m., revealed that the resident room door of room #A 105 contained a 1/4 of an inch gap at handle side of the door. The resident room door contained a side leaf for Geriatric use and did not have a door frame on the handle side.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility did not provide a directional exit signs at the end of a resident corridor for one of eight smoke compartments. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 6 residents.

Findings include:

Observation and interview on 9-6-16 at 10:45 a.m., revealed the exit sign located on the east end of the Entrance 3 corridor was obstructed by a ceiling header.

According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff (A) verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 6 residents.

Findings include:

Observations and interview on 9-6-16, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the Surgery Parts Washer room.
2. Smoke detector next to air diffuser in the Dining room next to the south wall.

Maintenance Staff (A) verified these observations.

Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that Main Sprinkler Riser gauges are calibrated. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 6.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

Observation and interview on 9-6-16 at approximately 11:00 a.m., showed Sprinkler Riser located in the Emergency Preparedness Storage and the Out Side Riser room contained gauges dated 2009. Gauges need to be replaced or recalculated every 5 years.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of four smoke zones. The facility had a capacity of 25 and a census of 6 at the time of survey.

Findings include:

Observation and interview on 9-6-16 at approximately 11:37 a.m., revealed that in the Kitchen over the food preparation area the sprinkler head bulb was covered with dust.

Maintenance Staff (A) verified this observation.