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Based on observations and confirmed by staff, the facility failed to ensure that all egress routes are constructed and maintained as required.

Section 19.2.1 states every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

Section 7.2.2.4.5.1 states the height of guards required in 7.1.8 shall be measured vertically to the top of the guard from the surface adjacent thereto.

Section 7.1.8 states guards in accordance with 7.2.2.4 shall be provided at the open sides of means of egress that exceed 30 in. (760 mm) above the floor or the finished ground level below.

Section 7.2.2.4.5.2 states guards shall be not less than 42 in. (1065 mm) high, except as permitted by one of the following:
(1) Existing guards within dwelling units shall be permitted to be not less than 36 in. (915 mm) high.
(2) The requirement of 7.2.2.4.5.2 shall not apply in assembly occupancies where otherwise provided in Chapters 12
and 13.
(3) Existing guards on existing stairs shall be permitted to be not less than 30 in. (760 mm) high.

Section 7.2.2.3.3.1 states stair treads and landings shall be solid, without perforations, unless otherwise permitted in 7.2.2.3.3.4.

Section 7.7.3.4 states stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 5/15/17 and 5/16/17 revealed the following deficiencies:

1) Stairwell "A", stairwell "C", and the second floor corridor by the kitchen all terminate to the facility's exterior loading dock. The loading dock which travels the entire length of the building is approximately 10' in depth and 38"-40" above grade level in most locations. The loading dock is not equipped with any type of guard rail system to ensure accidental traversing off the platform. Upon exiting stairwell "A", approximately 75' of travel distance must be traversed along the loading dock before arriving to grade level. Upon exiting stairwell "C" and the corridor door exit, approximately 10' of travel distance must be traversed across the loading dock prior to reaching a set of concrete steps. The way these egress routes are currently configured, all who exit the facility in these locations have the potential for walking straight off the loading dock.

2) Outside of stairwell "A" there is an approximate 3' x 14' perforated metal grate in the direct path of egress. The grate perforations measure 1" x 3-1/2" in size. The perforations pose a severe tripping hazard for all of those trying to traverse this egress route.

3) The termination point to grade level from Stairwell "C" is on the second floor level. However, this stairwell travels down one more flight to the first floor level. The stairwell is not equipped with a means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation.

As a result, the facility failed to comply with the various sections of chapter 7 regarding exit discharge, exit location, and exit access as stated above.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Risk Management, and Director of Maintenance during the exit conference.

Based on observations the facility failed to ensure that hazardous areas are protected in accordance with the 2012 edition of NFPA 101 Life safety Code.
-Chapter 19 Section 19.3.2.1 states any hazardous area shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1
-Chapter 19 Section 19.3.2.1.3 requires that doors protecting hazardous areas be self or automatic closing.
-Chapter 19 Section 19.3.2.1.5 (5) lists rooms with soiled linen in volume exceeding 64 gallons (242 L) as a hazardous areas

Findings Include:

While conducting the facility tour during the afternoon hours of 5/16/17 observations revealed that the second floor soiled linen room, which houses soiled linen containers in excess of 64 gallons, is not equipped with a self or automatic closing device as required. The door is provided with an embossed placard which identifies the door as Facility Door C-216.

Note: The facility is housed in a non-sprinklered building and all hazardous areas are protected with at least a 1-hour fire resistive rating.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.2.1.3.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Risk Management, and Director of Maintenance during the exit conference.

Based on observations the facility failed to ensure that corridor doors are in compliance with the 2012 edition of NFPA 101 Life Safety Code.
-Chapter 19 Section 19.3.6.3.16 states fixed fire window assemblies in accordance with Section 8.3 shall be permitted in corridor doors.
-Chapter 19 Section 19.3.6.3.17 states restrictions in area and fire resistance of glass and frames required by Section 8.3 shall not apply in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.

Findings Include:

While conducting the facility during the afternoon hours of 05/16/17 observations revealed that the corridor entrance door to the second floor cafeteria is equipped with an approximately twenty-eight (28) inch by twenty (20) inch non-rated vision panel. The facility is located in a non-sprinklered building and as a result corridor doors must comply with Chapter 19 Section 19.3.6.3.16.

At time of finding, facility staff stated that the door was originally equipped with a fire-rated window but due to breakage the window was replaced with a non-rated piece of glass.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.6.3.16.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Risk Management, and Director of Maintenance during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that the essential electrical system is monitored as required.

Section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.

Section 9.1.3 states where required for compliance with this Code, emergency generators and standby power systems shall comply with sections 9.1.3.1 and 9.1.3.2.

Section 9.1.3.1 states emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 section 7.12.2 states when EPSSs are installed in health care facilities, the installation of the EPSS shall also be in compliance with NFPA 99, "Health Care Facilities Code".

NFPA 99 section 6.4.1.1.17 states a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:

(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning

(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

Section 6.4.1.1.17.1 states a remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel.

THE FINDINGS INCLUDE:

During the afternoon hours of 5/15/17 while reviewing the emergency electrical system, it was observed that the two remote annunciator panels (one for each generator) are located in the main boiler room. Although there is a work station within the room, it is only occupied during the 7:00 A.M. - 3:00 P.M. working shift. The facility is not equipped with a remote audible common alarm at a location readily observed by operating personnel at a regular work station for either of the generator systems.

As a result, the facility failed to comply with NFPA 99 section 6.4.1.1.17.1 requiring an audible alarm to be located at a regularly work site observable by personnel.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Risk Management, and Director of Maintenance during the exit conference.