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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.

Findings Include:

While inspecting smoke barrier walls on August 27, 2014 at 12:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations in the following areas:

1. Smoke barrier wall near Emergency Waiting Room
2. Smoke barrier wall near Purchase Hall
3. Smoke barrier wall near Emergency Room X-Ray Hall

These deficient practices have the potential of affecting 3 of 5 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 the exits on August 27, 2014 at 1:00 p.m., the maintenance person and surveyor found required exit in the Dining Hall was not leading to the public way.

This deficient practice has the potential of affecting 1 of 5 smoke compartments.


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 fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

While reviewing documentation on August 27, 2014 at 9:30 a.m., the surveyor observed the facility did not provide fire drill documentation for past fire drills.

This deficient practice has the potential of affecting the entire facility. 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 a properly tested and maintained fire alarm system.

Findings Include:

While reviewing documentation on August 27, 2014 at 9:45 a.m., the surveyor observed the facility did not provide documentation for annually maintenance and monthly testing of the fire alarm system.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.


NFPA 101 section 9.6.1.4 states 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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Based on observation and testing, the facility failed to provide supervision on the sprinkler control valve in accordance NFPA 101 section 9.7.2.1, NFPA 72.

Findings Include:

While testing the sprinkler system on August 27, 2014 at 1:00 p.m., the maintenance person and surveyor revealed that a local alarm did not sound when the post indicator valve was closed to the facility.

This condition has the potential to affect all residents and staff of the facility.The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99.

Findings Include:

While reviewing documentation on August 27, 2014 at 10:00 a.m., the surveyor observed the facility did not provide documentation for annually maintenance and monthly load for the generator of the facility.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.

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.

Findings Include:

While inspecting smoke barrier walls on August 27, 2014 at 12:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations in the following areas:

1. Smoke barrier wall near Emergency Waiting Room
2. Smoke barrier wall near Purchase Hall
3. Smoke barrier wall near Emergency Room X-Ray Hall

These deficient practices have the potential of affecting 3 of 5 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 the exits on August 27, 2014 at 1:00 p.m., the maintenance person and surveyor found required exit in the Dining Hall was not leading to the public way.

This deficient practice has the potential of affecting 1 of 5 smoke compartments.


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 fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

While reviewing documentation on August 27, 2014 at 9:30 a.m., the surveyor observed the facility did not provide fire drill documentation for past fire drills.

This deficient practice has the potential of affecting the entire facility. 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 a properly tested and maintained fire alarm system.

Findings Include:

While reviewing documentation on August 27, 2014 at 9:45 a.m., the surveyor observed the facility did not provide documentation for annually maintenance and monthly testing of the fire alarm system.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.


NFPA 101 section 9.6.1.4 states 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, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Based on observation and testing, the facility failed to provide supervision on the sprinkler control valve in accordance NFPA 101 section 9.7.2.1, NFPA 72.

Findings Include:

While testing the sprinkler system on August 27, 2014 at 1:00 p.m., the maintenance person and surveyor revealed that a local alarm did not sound when the post indicator valve was closed to the facility.

This condition has the potential to affect all residents and staff of the facility.The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99.

Findings Include:

While reviewing documentation on August 27, 2014 at 10:00 a.m., the surveyor observed the facility did not provide documentation for annually maintenance and monthly load for the generator of the facility.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.