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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 zones. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 14 residents.

Findings include:

Observations and interview on 11/18/11, revealed the exit corridors in the following wings were not equipped with exit signs on the end of the corridors next to the smoke doors. It was observed that when the smoke doors are in the closed position, two exit signs were not visible. At approximately 11:35 a.m. the north end of the Radiology/Lab corridor was missing an exit sign next to the smoke doors affecting staff.

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 record review and interview, the facility failed to maintain and test smoke detectors for functionality in accordance with NFPA 72. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. This facility has a capacity of 25 and a census of 25 residents.

Findings include:

Observation and interview on 11/18/11, the facility was unable to produce documentation that the smoke detectors and Main Fire Alarm System had a functional test semi annually as required. The Main Fire Alarm Panel was inspected on 1/21/11 by Primary Systems and had not been inspected after that date. Phone conversation with a Primary Systems representative it was determined that the system was only inspected annually.

Maintenance Staff (A) verified the observations and scheduled the system inspections semi annually.

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 14 residents.

Findings include:

Observation and interview on 11/18/11 at approximately 11:40 a.m., revealed in the 1968 Surgery Corridor area next to the smoke doors the smoke detector was closer then three feet of a air diffuser.

Maintenance Staff (A) verified the observation.

Based on record review and interview, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of eight smoke compartments in the building . This facility has a capacity of 25 and a census of 14 residents.

Findings include:

During the record review and interview of the facility ' s fire safety components on 11/18/11, revealed that the Hood Suppression System was inspected on 1-21-11 by Proshield Fire Systems. The facility was unable to provide documentation of an inspection for the system six months after the 1-21-11 inspection.

Maintenance Staff (A) confirmed this record review and contacted Proshield. Proshield inspected the suppression system the day of the survey.

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 zones. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 14 residents.

Findings include:

Observations and interview on 11/18/11, revealed the exit corridors in the following wings were not equipped with exit signs on the end of the corridors next to the smoke doors. It was observed that when the smoke doors are in the closed position, two exit signs were not visible. At approximately 11:35 a.m. the north end of the Radiology/Lab corridor was missing an exit sign next to the smoke doors affecting staff.

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 record review and interview, the facility failed to maintain and test smoke detectors for functionality in accordance with NFPA 72. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. This facility has a capacity of 25 and a census of 25 residents.

Findings include:

Observation and interview on 11/18/11, the facility was unable to produce documentation that the smoke detectors and Main Fire Alarm System had a functional test semi annually as required. The Main Fire Alarm Panel was inspected on 1/21/11 by Primary Systems and had not been inspected after that date. Phone conversation with a Primary Systems representative it was determined that the system was only inspected annually.

Maintenance Staff (A) verified the observations and scheduled the system inspections semi annually.

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 14 residents.

Findings include:

Observation and interview on 11/18/11 at approximately 11:40 a.m., revealed in the 1968 Surgery Corridor area next to the smoke doors the smoke detector was closer then three feet of a air diffuser.

Maintenance Staff (A) verified the observation.

Based on record review and interview, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of eight smoke compartments in the building . This facility has a capacity of 25 and a census of 14 residents.

Findings include:

During the record review and interview of the facility ' s fire safety components on 11/18/11, revealed that the Hood Suppression System was inspected on 1-21-11 by Proshield Fire Systems. The facility was unable to provide documentation of an inspection for the system six months after the 1-21-11 inspection.

Maintenance Staff (A) confirmed this record review and contacted Proshield. Proshield inspected the suppression system the day of the survey.