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Based on observation, 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. This condition affected 1 of 5 smoke compartments.

Findings include:

On October 10, 2012 at 11:30 a.m., the maintenance person and the the surveyor found that the Storage Room containing X-Ray film needed a door closure installed.

The maintenance supervisor and the administrator were notified during an 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. This condition had the potential to affect 1 of 5 required exits.

Findings Include:

On October 10, 2012 at 12:00 p.m., the maintenance person and surveyor found 1 of the 5 required exits to be inaccessible. The exit from the LDR wing lacked an all weather surface that continued to the public way.

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 fire drill documentation on October 10, 2012 at 1:00 p.m., the surveyor observed the facility was unable to provide fire drill documentation for past fire drills including date, time, what shift, and personnel attending the fire drill. No documentation was provided for the first quarter of 2012.

The administrator and the maintenance director were notified during the facility as well as the exit.

Based on observation and testing, the facility failed to provide a fire alarm system with approved component, devices or equipment installed according to NFPA 72, national Fire Alarm Code to provide effective warning of fire in any part of the building. This condition affected all smoke compartments.

Findings include:

On October 10, 2012, at 12:30 p.m., the maintenance person and surveyor found that the visual components of the fire alarm were not synchronized. The off-site forces notification device is located in a space not equipped with a line voltage operated smoke detector.

The maintenance supervisor and the administrator were notified during an exit conference.

NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

Based on observation, 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. This condition affected 1 of 5 smoke compartments.

Findings include:

On October 10, 2012 at 11:30 a.m., the maintenance person and the the surveyor found that the Storage Room containing X-Ray film needed a door closure installed.

The maintenance supervisor and the administrator were notified during an 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. This condition had the potential to affect 1 of 5 required exits.

Findings Include:

On October 10, 2012 at 12:00 p.m., the maintenance person and surveyor found 1 of the 5 required exits to be inaccessible. The exit from the LDR wing lacked an all weather surface that continued to the public way.

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 fire drill documentation on October 10, 2012 at 1:00 p.m., the surveyor observed the facility was unable to provide fire drill documentation for past fire drills including date, time, what shift, and personnel attending the fire drill. No documentation was provided for the first quarter of 2012.

The administrator and the maintenance director were notified during the facility as well as the exit.

Based on observation and testing, the facility failed to provide a fire alarm system with approved component, devices or equipment installed according to NFPA 72, national Fire Alarm Code to provide effective warning of fire in any part of the building. This condition affected all smoke compartments.

Findings include:

On October 10, 2012, at 12:30 p.m., the maintenance person and surveyor found that the visual components of the fire alarm were not synchronized. The off-site forces notification device is located in a space not equipped with a line voltage operated smoke detector.

The maintenance supervisor and the administrator were notified during an exit conference.

NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.