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Based on observation and interview, the facility failed to protect corridor openings as required.

Findings include:

On 10/28/15, the following corridor doors were equipped with latches that did not keep the door closed. Fire protective equipment is required to be maintained. The following doors were not maintained as required.
· G708-basement
· A409-one of two leaves
· A407
· E235
· E239
· E248
· A107- electric latch, could not confirm that latch would be engaged with loss of power.
The Maintenance Foreman was present when the deficiency was identified.

Failure to protect corridor openings as required increases the risk of death or injury due to fire.

The deficiency affected seven of numerous corridor doors in the building.

Ref: 2000 NFPA 101 Section 19.3.6.3.2, 4.6.12.1

Based on observation and interview, the facility failed to mark the means of egress as required.

Findings include:

On 10/28/15, an exit sign marked the following locations as a means of egress when it was not the means of egress. Exit access corridors are required to provide access to no less than two exits without passing through any intervening rooms other than corridors, lobbies and other spaces permitted to be open to the corridor.
· Door A409 marked with exit sign that led to corridor suite door. Suite is not permitted to be open to the corridor.

Ref: 2000 NFPA 101 Section 19.2.10.1, 19.2.5.9, 7.5.1.2

On 10/28/15, exit signs at the following locations did not have directional indicators as required.

· Door J510 need chevron to direct to doors without locks in direction of egress
· Door J724 need chevron to direct to doors without locks in direction of egress

Ref: 2000 NFPA 101 Section 19.2.10.1, 7.10.2

The Maintenance Foreman was present when the deficiency was identified.

Failure to mark the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected three of numerous means of egress in the building.

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 10/28/15, the following storage rooms were found to have doors that were not self-closing. Storage rooms that exceed 50 sf in size and contain combustible materials are considered hazardous areas. Doors to hazardous areas are required to be self-closing.
· Door E229- closer needs adjustment
· C408- lab, closer needs adjustment

Ref: 2000 NFPA 101 Section 19.3.2.1

On 10/28/15, the following doors protecting openings to hazardous areas were not being held open as permitted. Hold open devices on doors to hazardous areas are required to release upon detection of smoke by smoke detectors for door release service.

· Kitchen storage room- friction hold open

Ref: 2000 NFPA 101 Section 19.3.2.1, 7.2.1.8.2, 1999 NFPA 72 Section 2-10.6

The Maintenance Foreman was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected two of eight resident smoke compartments.

Based on observation and interview, the facility failed to provide exit enclosures as required.

Findings include:

On 10/28/15, the following exit stair did not discharge to an exit passageway with the same fire resistance rating as required for the stair enclosure. Exit stair enclosures serving 3 stories or less are required to be constructed to 1 hour fire resistance rating with openings protected with 1 hour fire resistance rated doors. The exit passageway openings were not protected with 1 hour fire resistance rated doors as required.
· East stair- 5 openings in the exit passageway were equipped with 20 minute doors.
· West stair- exit passageway not identified on drawing as 1 hour rated.

The Maintenance Foreman was present when the deficiency was identified.

Failure to provide exit enclosures as required increases the risk of death or injury due to fire.

The deficiency affected two of two exit stairs.

Ref: 2000 NFPA 101 Section 19.2.2.3, 7.2.2.5.1, 7.1.3.2.1, 7.1.3.2.2, 19.2.7, 7.7.1, 7.2.6.3, 8.2.3.2.3.1

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 10/28/15, the following doors were not arranged to be opened readily from the egress side whenever the building is occupied.

· Door D411- doors were not operable egressing from physical therapy area as the doors did not open in the direction of egress and did not have handles. (manual operation must be provided)

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1

The Maintenance Foreman was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous doors in the means of egress.

Based on records review and interview, the facility failed to provide a fire plan as required.

Findings include:

On 10/27/15, the fire plan did provide for evacuation of smoke compartment as required.
The Maintenance Foreman was present when the deficiency was identified.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected one of eight required components of the fire plan.

Ref: 2000 NFPA 101 Section 19.7.1.1, 19.7.2.2

Based on records review, the facility failed to conduct fire drills as required.

Findings include:

On 10/27/15, records show 3rd shift fire drills in the past year were conducted at 8:42, 9:09, 9:00 and 9:00pm. Fire drills are required to be conducted under varying conditions. Time in the shift is one of the conditions. The shift is eight (8) hours long. All of third shift drills in the past year were conducted within a 1/2 hour variation or in the past year.
The Safety Officer was present when the deficiency was identified.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected one of three shifts.

Ref: 2000 NFPA 101 Section 19.7.1.2

Based on observation and interview, the facility failed to test the fire alarm system as required.

Findings include:

On 10/29/15, there was no records of testing of the fire alarm system. The fire alarm system has been in operation since May 2015. There was no record of initial system testing.

The Maintenance Foreman was present when the deficiency was identified.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected the entire building.

Ref: 2000 NFPA 101 Section 4.6.12.2; 1999 NFPA 72 7-1.6.1

Based on observation and interview, the facility failed to continuously maintain and / or test and inspect automatic sprinklers in reliable operating condition.

Findings include:

On 10/29/15, there was no records of testing of the automatic sprinkler system. The sprinkler system has been in operation since May 2015. Quarterly testing had not been completed.

The Maintenance Foreman was present when the deficiency was identified.

Failure to increases the risk of death or injury due to fire.

The deficiency affected the entire building.

Ref: 2000 NFPA 101 Section 4.6.12.2; 1998 NFPA 25 Table 2-1, Section 2.3.3

Based on observation and interview, the facility failed to maintain the means of egress reliability as required.

Findings include:

On 10/28/15, at the following locations, furnishings, decorations or objects obstructed exits, access thereto, egress therefrom of visibility thereof. Curtains, draperies are not permitted to conceal or obscure any exit access.
· Physical Therapy privacy curtain obstructed access and visibility of exit access corridor door.

The Maintenance Foreman was present when the deficiency was identified.

Failure to maintain the reliability of the means of egress increases the risk of death or injury due to fire.

The deficiency affected one of numerous exit access doors.

Ref: 2000 NFPA 101 Section 19.2.1, 7.5.2.2, 7.1.10.1

Based on observation and interview, the facility failed to protect penetrations in smoke barriers as required.

Findings include:

On 10/28/15, the smoke barrier locations listed below were unsealed where the penetration would not resist the passage of smoke. Penetrations in smoke barriers are required to be filled with material that will resist the passage of smoke or be protected by an approved device that is designed for the specific purpose.
· Above D130 OB ward corridor door, 3 com cables
· Above corridor door D303. 2each, 2in x 2 in
· Above corridor door D425, 1.5 inch diameter, 6 com cables
· Above cross door D601, 2 com cables

The Maintenance Foreman was present when the deficiency was identified.

Failure to protect penetrations in smoke barriers increases the risk of death or injury due to fire.

The deficiency affected 4 of 8 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.7.3, 8.3.6.1