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Based on review of facility documentation, facility observation and staff confirmation, the facility failed to ensure that if the building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/24/14 between 8:45 A.M. and 11:45 A.M., tour of the facility was conducted with Staff T, A and U. Review of the facility schematic revealed a two hour fire rated barrier between the original building, construction type II(111) and the 2004 addition, construction type V(111).

Observation above the ceiling tiles on the first and second floors of the original building revealed the following penetrations:

1. Located on the second floor, above the fire rated doors between the two buildings, two penetrations were noted. One was approximately one inch in diameter and the other approximately one fourth inch in diameter. Blue wiring was passing through the penetrations.

2. Located on the first floor, above the fire rated doors located near room 110, five penetrations were drilled through the fire rated barrier. The penetrations varied in size from approximately one half inch to one inch in diameter. Wires were passing through two of the five holes.

Staff T observed and confirmed the penetrations in the two hour fire rated wall on both floors of the facility.

Based on review of facility documentation, facility observation and staff confirmation, the facility failed to ensure smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/24/14 between 8:45 A.M. and 11:45 A.M. tour of the facility was conducted with Staff T, A and U. Review of the facility schematic revealed a smoke barrier wall dividing the second floor. Observation above the ceiling tiles at the smoke barrier doors, on the second floor, revealed an unsealed pipe used as a sleeve for wiring that penetrated the smoke barrier wall. The pipe was approximately two inches in diameter and was observed to penetrate both sides of the smoke barrier wall.

Staff T present at the observation confirmed the finding.

Based on facility observation and staff confirmation, the facility failed to ensure illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/24/14 between 8:45 A.M. and 11:45 A.M. tour of the facility was conducted with Staff T, A and U. Observation of an exit discharge located on the first floor at the dock hallway revealed only one light present at the exit discharge.

Interview of Staff T confirmed that if the bulb in the single light at the exit discharge failed, the area would be dark.

Based on review of facility preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the fire alarm system required for life safety was tested, and maintained in accordance with NFPA 72. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/25/14 between 8:00 A.M. and 11:45 A.M. review of facility maintenance documentation was completed. Review of the fire alarm testing information revealed a contracted, licensed company inspected the fire alarm system on May 1, 2013. Review of the inspection report revealed that all devices related to the fire alarm system were listed as inspected, tested and the results of the tests documented.

Interview of Staff T regarding an annual fire alarm test completed in 2014, revealed the same company conducted an inspection in April 2014. There was no documented evidence that all components of the fire alarm system had been inspected and tested during the April 2014 inspection. Staff T indicated the contracted company had been contacted to provide the documentation of the testing but was informed the report was not complete.

Based on review of facility preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the fire alarm system required for life safety was tested, and maintained in accordance with NFPA 72. The facility had a bed capacity of 114 beds with a census of 113 patients. Potentially any patient, visitor or staff receiving services in the facility could be affected.

Findings include:

On 09/25/14 between 8:00 A.M. and 11:45 A.M. review of facility maintenance documentation was completed. Review of the fire alarm testing information revealed a contracted, licensed company inspected the fire alarm system on May 1, 2013. Review of the inspection report revealed that all devices related to the fire alarm system were listed as inspected, tested and the results of the tests documented.

Interview of Staff T regarding an annual fire alarm test completed in 2014, revealed the same company conducted an inspection in April 2014. There was no documented evidence that all components of the fire alarm system had been inspected and tested during the April 2014 inspection. Staff T indicated the contracted company had been contacted to provide the documentation of the testing but was informed the report was not complete.

Based on review of facility preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the required automatic sprinkler systems were continuously maintained in reliable operating condition and inspected periodically. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/25/14 between 8:00 A.M. and 11:45 A.M. review of facility maintenance documentation was completed. Review of the automatic sprinkler system testing information revealed a contracted, licensed company inspected the sprinkler system in January and July 2014. Review of the inspection reports indicated they were semi-annual inspections.

Interview of Staff T regarding inspection of sprinkler system components required on a quarterly schedule confirmed that no quarterly inspection of the sprinkler system was conducted.

NFPA 101
Chapter 7
7.10.1.2


Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on facility tour and staff interview and confirmation, the facility failed to ensure the exits, other than main exterior exit doors that are obvious and clearly identifiable were marked readily visible from any direction of exit access. The facility had an occupancy load of 10 residents. Ten residents resided in the building.

Findings include:

On 09/24/14 between 3:00 P.M. and 5:00 P.M. tour of the business/residential facility was conducted with Staff V. Observation of the lower level of the building revealed lighted exit signs identified the way out. Following the exit signs from the TV/lounge area to a small room where two doors were present revealed it was not clear which door was the way to the exit. Staff V present on tour revealed which door lead to the stairs and the exit discharge. Staff V confirmed that exit signage needed to be posted at the bottom of the stairs to show the way out.

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NFPA 101,
Chapter 21

Emergency illumination is provided in accordance with section 7.9.

Based on facility tour, review of facility documentation and staff interview and confirmation, the facility failed to ensure emergency illumination was provided in accordance with section 7.9. with regards to testing the emergency lights for 30 seconds per month and 90 minutes annually. The facility had an occupancy load of 10 residents. Ten residents resided in the building.

Findings include:

On 09/24/14 between 3:00 P.M. and 5:00 P.M. tour of the business/residential building was conducted with Staff V. Observation of the building revealed emergency battery back-up lighting was present on all levels of the building.

Review of the building maintenance information with Staff W revealed no documented evidence the emergency lighting was tested for 30 seconds each month. There was no documented evidence the emergency lighting had been tested for 90 minutes in the past 12 months. Staff W confirmed the documentation did not reflect the length of the monthly tests or that annual testing had been completed.

Based on review of facility documentation, facility observation and staff confirmation, the facility failed to ensure that if the building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/24/14 between 8:45 A.M. and 11:45 A.M., tour of the facility was conducted with Staff T, A and U. Review of the facility schematic revealed a two hour fire rated barrier between the original building, construction type II(111) and the 2004 addition, construction type V(111).

Observation above the ceiling tiles on the first and second floors of the original building revealed the following penetrations:

1. Located on the second floor, above the fire rated doors between the two buildings, two penetrations were noted. One was approximately one inch in diameter and the other approximately one fourth inch in diameter. Blue wiring was passing through the penetrations.

2. Located on the first floor, above the fire rated doors located near room 110, five penetrations were drilled through the fire rated barrier. The penetrations varied in size from approximately one half inch to one inch in diameter. Wires were passing through two of the five holes.

Staff T observed and confirmed the penetrations in the two hour fire rated wall on both floors of the facility.

Based on review of facility documentation, facility observation and staff confirmation, the facility failed to ensure smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/24/14 between 8:45 A.M. and 11:45 A.M. tour of the facility was conducted with Staff T, A and U. Review of the facility schematic revealed a smoke barrier wall dividing the second floor. Observation above the ceiling tiles at the smoke barrier doors, on the second floor, revealed an unsealed pipe used as a sleeve for wiring that penetrated the smoke barrier wall. The pipe was approximately two inches in diameter and was observed to penetrate both sides of the smoke barrier wall.

Staff T present at the observation confirmed the finding.

Based on facility observation and staff confirmation, the facility failed to ensure illumination of means of egress, including exit discharge, was arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/24/14 between 8:45 A.M. and 11:45 A.M. tour of the facility was conducted with Staff T, A and U. Observation of an exit discharge located on the first floor at the dock hallway revealed only one light present at the exit discharge.

Interview of Staff T confirmed that if the bulb in the single light at the exit discharge failed, the area would be dark.

Based on review of facility preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the fire alarm system required for life safety was tested, and maintained in accordance with NFPA 72. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/25/14 between 8:00 A.M. and 11:45 A.M. review of facility maintenance documentation was completed. Review of the fire alarm testing information revealed a contracted, licensed company inspected the fire alarm system on May 1, 2013. Review of the inspection report revealed that all devices related to the fire alarm system were listed as inspected, tested and the results of the tests documented.

Interview of Staff T regarding an annual fire alarm test completed in 2014, revealed the same company conducted an inspection in April 2014. There was no documented evidence that all components of the fire alarm system had been inspected and tested during the April 2014 inspection. Staff T indicated the contracted company had been contacted to provide the documentation of the testing but was informed the report was not complete.

Based on review of facility preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the fire alarm system required for life safety was tested, and maintained in accordance with NFPA 72. The facility had a bed capacity of 114 beds with a census of 113 patients. Potentially any patient, visitor or staff receiving services in the facility could be affected.

Findings include:

On 09/25/14 between 8:00 A.M. and 11:45 A.M. review of facility maintenance documentation was completed. Review of the fire alarm testing information revealed a contracted, licensed company inspected the fire alarm system on May 1, 2013. Review of the inspection report revealed that all devices related to the fire alarm system were listed as inspected, tested and the results of the tests documented.

Interview of Staff T regarding an annual fire alarm test completed in 2014, revealed the same company conducted an inspection in April 2014. There was no documented evidence that all components of the fire alarm system had been inspected and tested during the April 2014 inspection. Staff T indicated the contracted company had been contacted to provide the documentation of the testing but was informed the report was not complete.

Based on review of facility preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure the required automatic sprinkler systems were continuously maintained in reliable operating condition and inspected periodically. The facility had a bed capacity of 114 beds with a census of 113 patients.

Findings include:

On 09/25/14 between 8:00 A.M. and 11:45 A.M. review of facility maintenance documentation was completed. Review of the automatic sprinkler system testing information revealed a contracted, licensed company inspected the sprinkler system in January and July 2014. Review of the inspection reports indicated they were semi-annual inspections.

Interview of Staff T regarding inspection of sprinkler system components required on a quarterly schedule confirmed that no quarterly inspection of the sprinkler system was conducted.

NFPA 101
Chapter 7
7.10.1.2


Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on facility tour and staff interview and confirmation, the facility failed to ensure the exits, other than main exterior exit doors that are obvious and clearly identifiable were marked readily visible from any direction of exit access. The facility had an occupancy load of 10 residents. Ten residents resided in the building.

Findings include:

On 09/24/14 between 3:00 P.M. and 5:00 P.M. tour of the business/residential facility was conducted with Staff V. Observation of the lower level of the building revealed lighted exit signs identified the way out. Following the exit signs from the TV/lounge area to a small room where two doors were present revealed it was not clear which door was the way to the exit. Staff V present on tour revealed which door lead to the stairs and the exit discharge. Staff V confirmed that exit signage needed to be posted at the bottom of the stairs to show the way out.

**********************************************************************

NFPA 101,
Chapter 21

Emergency illumination is provided in accordance with section 7.9.

Based on facility tour, review of facility documentation and staff interview and confirmation, the facility failed to ensure emergency illumination was provided in accordance with section 7.9. with regards to testing the emergency lights for 30 seconds per month and 90 minutes annually. The facility had an occupancy load of 10 residents. Ten residents resided in the building.

Findings include:

On 09/24/14 between 3:00 P.M. and 5:00 P.M. tour of the business/residential building was conducted with Staff V. Observation of the building revealed emergency battery back-up lighting was present on all levels of the building.

Review of the building maintenance information with Staff W revealed no documented evidence the emergency lighting was tested for 30 seconds each month. There was no documented evidence the emergency lighting had been tested for 90 minutes in the past 12 months. Staff W confirmed the documentation did not reflect the length of the monthly tests or that annual testing had been completed.