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Based on observation, the facility failed to provide exit signage that is in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 4 of 7 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects 17 patients in the facility.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
Or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on May 19, 2011 between 2:30 p.m. and 4:30 p.m., the facility failed to provide exit signage that are completely lit or shows the direction of travel to reach the nearest exit.

1. Three of the exit signs in the building have bulbs that are burnt.

2. There is no exit signage going into or coming from the Administrative area from the core area. Without an exit sign in this area it is not clear if the door to this area is an exit.

Based on observations the facility failed to provide smoke barriers that were constructed with at least a one-half hour fire resistance rating for 1 of 1 wall. This deficiency affects 2 of 2 smoke compartments and all 17 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Findings:

During facility tour on May 19, 2011 between 2:30 p.m. and 4:30 p.m., the integrity of a smoke barrier wall was observed to be compromised in the following area.

1. A piece of drywall in the attic area between the day room and room 8 is missing. The piece is two feet by three feet and has been broken and falling off.

Based on observation the facility failed to provide proper protection for 5 of 9 hazardous areas as per NFPA 101 (Life Safety Code). This deficiency affects 17 patients in the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility on May 19, 2011 between 2:30 p.m. and 4:30 p.m., it was observed that the following hazardous areas did not have doors that were self-closing or walls that resist the passage of smoke.

1. The door to the central supply room (room 3) was not self-closing.
2. The door to the medical records office (room 4) was not self-closing.
3. The door to the wound care office (room 9) was not self-closing.
4. The door to the clean supply room (room 16) was not self-closing.
5. The door to the oxygen supply room (by room 16) was not self-closing.