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Based on visual observation the facility failed to provide exit signage for all required exits. Exit signs provide a route for occupants to reach safety. The deficient practice had the potential to affect 8 of 8 residents. 1 of 6 exits have signage that is deficient.

Findings:

During the facility tour on 05/13/2015, between the hours of 8:30am and 12:30pm, it was observed that above the exit signs above the exit door leading through the therapy area were not in working order.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 8 of the 8 residents of the facility.

Findings:

During the facility tour on 05/13/2015, between the hours of 8:30am and 12:30pm, it was observed that the storage room at the end of the kitchen hallway had several 3/4 inch to 1/2 inch pipes and conducts that had 3/4 to 1/2 gaps going through the rated wall that were not sealed to resist the passage of smoke.

Based on visual observation the facility failed to provide exterior emergency lighting with two bulbs in order to prevent total darkness when one bulb fails. Additionally, the exit discharge, at all required exits, shall be provided with lighting in emergency situations during nighttime hours. The deficient practice had the potential to affect 8 of 8 residents. 4 of 6 exits had emergency lighting that was deficient.

Findings:

During the facility tour on 05/13/2015, between the hours of 8:30am and 12:30pm, it was observed that the all exits located through out the facility except the front two exits, did not have a double lighted fixture which would leave residents in darkness in the event of a fire/smoke emergency evacuation.

Based on visual observation and interview the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 8 of the 8 residents of the facility.


Findings:
During the facility tour on 05/13/2015, between the hours of 8:30am and 12:30pm it was observed that the fire alarm system is yellow tagged because of a bad smoke detector in the kitchen area. The fire alarm system is functional at this time.


Actual NFPA Standard: NFPA 101, 9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
Actual NFPA Standard: NFPA 101, 9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
Actual NFPA Standard: NFPA 72, 3-9.6.3. All door hold-open release and integral door release and closure devices used for release service shall be monitored for integrity in accordance with 3-9.2.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13 & 25. This deficiency has the potential to affect 8 of the 8 residents of the facility.

Findings:
1)- During the facility tour and record review on 05/13/2015, between the hours of 8:30am and 12:30pm, it was observed that the sprinkler system is not being inspected quarterly has per NFPA-25. According to the last inspection report and current green tag on the system the last certification inspection was conducted in Dec/2014. There is a green service tag located on the system dated May/2015.

2)- During the facility tour on 05/13/2015, between the hours of 8:30am and 12:30pm, it was observed that the top piping in the outside sprinkler riser closet is not protected from freezing temperatures below 40 degrees. The bottom of the piping is protected but stops about 2 foot from the ground.