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Based on observation, the facility failed to provide approved construction type for a non-sprinkled building.

Findings include:

On June 26, 2012 at 12:30 p.m., it was observed that the 1977 addition is a type II(000) construction and is not sprinkler protected.

These deficient practices have the potential of effecting the entire facility.

The maintenance supervisor and the administrator were notified during an 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. This condition has the potential to affect about 25% of the residents and staff.

On June 26, 2012 at 11:45 a.m., the maintenance supervisor and the surveyor observed the smoke barrier wall located next to the main entrance had the unsealed penetrations around the med gas lines and around newly installed cables.

This deficient practice has the potential of affecting 2 of 4 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. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

On June 26, 2012 at 11:30 a.m., the maintenance person and the the surveyor found the one hour enclosure for the gas fired Water Heater Room had penetrations in the wall around newly installed electrical conduit.

This deficient practice has the potential of affecting 1 of 4 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. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

On June 26, 2012 at 1:00 p.m., the maintenance person and surveyor found 1 of the 5 required exits to be inaccessible. The exit from west patient wing of the facility lacked an all weather surface 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.

This deficient practice has the potential of affecting 1 of 4 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.