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Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on March 26, 2013 at 10:30 a.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located next to the pharmacy had a small penetration around some wiring that penetrated the smoke barrier wall.

This deficient practice has the potential of affecting 1 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on March 26, 2013 at 10:30 am, the maintenance person and the the surveyor found the following hazardous areas to have deficiencies:
1. The Pantry lacks a self closing device and seal penetrations around conduit.
2. X-Ray File Storage Room lacked a self closing device.

These deficient practices have the potential of affecting 2 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05.

Findings Include:

While inspecting exit access on March 26, 2013 at 11:00 a.m., the maintenance person and surveyor found 1 of the 6 required exits to be inaccessible. The exit from the senior care unit lacked an all weather surface to the public way.

This deficient practice has the potential of affecting 1 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on March 26, 2013 at 10:30 a.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located next to the pharmacy had a small penetration around some wiring that penetrated the smoke barrier wall.

This deficient practice has the potential of affecting 1 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on March 26, 2013 at 10:30 am, the maintenance person and the the surveyor found the following hazardous areas to have deficiencies:
1. The Pantry lacks a self closing device and seal penetrations around conduit.
2. X-Ray File Storage Room lacked a self closing device.

These deficient practices have the potential of affecting 2 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05.

Findings Include:

While inspecting exit access on March 26, 2013 at 11:00 a.m., the maintenance person and surveyor found 1 of the 6 required exits to be inaccessible. The exit from the senior care unit lacked an all weather surface to the public way.

This deficient practice has the potential of affecting 1 of 6 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.