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Based on observation and record review, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation at 10:30 a.m. on 12/03/14 revealed the original building was a two story, protected, ordinary Type III (200) structure with a basement. The building was not provided with a complete automatic sprinkler system. The top floor and attic were equipped with automatic sprinkler protection. Document review of previous survey data confirmed that construction type.

The facility meets FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and document review, the provider failed to maintain the 30 minute fire resistance rating of corridor wall assemblies. The walls did not extend to the roof deck above the lay-in acoustical ceiling. Findings include:

1. Observation at 11:00 a.m. on 12/03/14 revealed the corridor walls extended only approximately six inches above the lay-in acoustical ceiling and did not extend to the roof deck. Document review of previous survey reports also identified that condition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain the fire rating of corridor wall assemblies for the first floor at the assisted living dining room (the double-doors to the main lobby were unrated and not latching into the frame). Findings include:

1. Observation at 2:00 p.m. on 12/03/14 revealed the double-doors from the assisted living dining room to the hospital entrance lobby each had fifteen panes of glass (each approximately 12 inches by 15 inches) that were not fire-rated (did not meet the 20 minute corridor door equivalency requirement). Interview with the maintenance supervisor at the time of the observation confirmed that condition.

2. Observation and testing at 2:15 p.m. on 12/03/14 revealed the west leaf (slave leaf) of the double-doors from the assisted living dining room to the hospital main entrance lobby would not latch into the door frame when tested. The leaf had a manual throw bolt at the top of the door that appeared to have a hole in the door frame to seat into when operated. The throw bolt and the hole were mis-aligned by one-half inch, and the bolt would not engage. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

The deficiencies could potentially affect all occupants of the facility.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the sliding glass window for the business office on the first floor. Findings include:

1. Observation at 1:30 p.m. on 12/03/14 revealed a set of sliding glass windows (approximately 20 inches by 30 inches) for the business office/reception on the first floor in the main lobby. The sliding glass windows were not smoketight (was not a fixed assembly and was not in an approved frame), was not equipped with a rollup door. The room was not equipped with smoke detection connected to the facility fire alarm system. The building was not completely sprinklered. Interview with the maintenance supervisor at the time of the observations confirmed those findings.

This deficiency could potentially affect all occupants of the facility.

Based on observation and document review, the provider failed to ensure the original elevator had a fire-resistive rating of at least one hour. Findings include:

1. Observation at 11:30 a.m. on 12/03/14 revealed the original elevator doors were not a fire rated assembly. They contained a wire glass vision panel approximately 11 inches by 35 inches. Document review of previous survey reports also confirmed that elevator did not have a one-hour fire-resistive rating.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and record review, the provider failed to install a complete automatic sprinkler system as required for the building construction type. Findings include:

1. Observation at 10:30 a.m. on 12/03/14 revealed the original building was a two story, protected, ordinary Type III (200) structure with a basement. The building was not provided with a complete automatic sprinkler system. The top floor and attic were equipped with sprinkler protection. Document review of previous survey data confirmed a complete automatic sprinkler system had not been provided.

The facility meets the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had all the required maintenance and inspections (quarterly flow testing, five year internal obstruction inspection, and annual backflow preventer testing) performed during the previous twelve months. Documentation was not available for the above. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at 1:15 p.m. on 12/03/14 revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the quarterly flow testing requirements.

2. Review of the provider's automatic sprinkler system inspection reports at 1:30 p.m. on 12/03/14 revealed documentation was not available regarding the required five year internal sprinkler system obstruction inspection. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the five year obstruction inspection requirements.

3. Review of the provider's automatic sprinkler system inspection reports at 1:45 p.m. on 12/03/14 documentation for the required annual backflow preventer testing was not available. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the backflow testing requirements.

These deficiencies could potentially affect all occupants of the facility.