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Based on observation and interview, the facility failed to maintain the self-closing doors in the exit passageway. This was evidenced by two doors that were secured in the open position, with hold-open devices that were not interfaced with the Fire Alarm system (FAS) for automated closure. This affected two of three smoke compartments, and could potentially allow the spread of smoke into adjoining compartments.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.2.2.7* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure
shall be permitted to be held open only by an automatic release
device that complies with 7.2.1.8.2. The automatic sprinkler
system, if provided, and the fire alarm system, and the
systems required by 7.2.1.8.2, shall be arranged to initiate the
closing action of all such doors throughout the smoke compartment
or throughout the entire facility.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed
shall not be secured in the open position at any time and shall
be self-closing or automatic-closing in accordance with
7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents,
as defined in 6.2.2.2 and 6.2.2.3, or where approved by the
authority having jurisdiction, door leaves shall be permitted to
be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes
self-closing.
(2) The release device is designed so that the leaf instantly
releases manually and, upon release, becomes selfclosing,
or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated
by the operation of approved smoke detectors installed
in accordance with the requirements for smoke
detectors for door leaf release service in NFPA 72, National
Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the holdopen
mechanism is released and the door leaf becomes
self-closing.

Findings:

During a facility tour and interview with the BS and LSO on 11/28/17, the self-closing doors in the exit passageway were observed.

At 1:45 p.m., the two single-leaf cross corridor doors located in the corridor beside the dumbwaiter were observed. Both doors were secured in the open position with friction hold-open devices. The doors did not release and close after fire alarm activation. Upon interview, the LSO and BS confirmed the findings.

Based on observation and interview, the facility failed to maintain the hazardous areas. This was evidenced by a self-closing enclosure opening door that failed to fully close and latch with testing. This affected one of three smoke compartments, and could result in a delay in containing smoke and/or fire to hazardous areas.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2 Protection from Hazards.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered
a severe hazard.

Findings:

During a facility tour and interview with the BS on 11/28/17, the hazardous areas were observed.

At 1:50 p.m., Storage Room 4015 was observed. The room was greater than 50 square feet in size (approximately 250 square feet) and used for multiple stored combustible items, including boxed items. The door was equipped with self-closing and positive latching devices. The door was opened to the fullest extent and allowed to close. The door failed to fully close and latch. Upon interview, the BS confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system. This was evidenced by the failure to provide a current annual sprinkler inspection report. This affected three of three smoke compartments, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.

4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.
4.3.1 Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6
5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.
5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.

Findings:

During a facility tour, document review, and interview with the FC on 11/28/17, the automatic fire sprinkler system was observed and records were requested.

At 11:12 a.m., the facility was observed with a wet automatic fire sprinkler system. No current or previous annual sprinkler inspection report was available for review. Upon interview, the FC confirmed the finding stating that facility staff are in the process of being trained and certified to perform the annual inspection.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed corridor penetration. This affected one of three smoke compartments, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility with the BS on 11/28/17, the corridor walls and ceilings were observed.

At 11:50 a.m., the walls and ceiling in the Corridor by Room 4029 were observed. There was an approximately one inch diameter ceiling penetration, with a cable traveling through it, located in the corner of the ceiling above Room 4029.

Based on observation, record review, and interview, the facility failed to maintain the elevators. This was evidenced by the failure to provide monthly inspections and testing for elevators with fire fighter emergency services. This affected three of three smoke compartments, and could potentially result in malfunction and harm to staff and residents.

NFPA 101, Life Safety Code, 2012 Edition.
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators,
and conveyors shall comply with the provisions of
Section 9.4.

9.4.6 Elevator Testing.
9.4.6.2 All elevators equipped with fire fighters' emergency operations
in accordance with 9.4.3 shall be subject to a monthly
operation with a written record of the findings made and kept on
the premises as required by ASMEA17.1/CSA B44, Safety Code for
Elevators and Escalators.


Findings:

During a facility tour, document review, and interview with the FC on 11/28/17, the elevators were observed and records were requested.


At 11:15 a.m., the facility was observed with three elevators that were equipped with fire fighters' emergency recall. No documentation was provided to show the fire fighters' emergency services on the elevators had been inspected and tested monthly. Upon interview, the FC confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by the failure to perform monthly battery electrolyte specific gravity testing. This affected three of three smoke compartments, and could result in a loss of power due to a generator malfunction during an emergency power outage.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.3.1 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, Standard for Emergency and Standby Power Systems, 2010 edition.
Chapter 8 Routine Maintenance and
Operational Testing
8.1* General.
8.1.1 The routine maintenance and operational testing program
shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following: (1)The date of the maintenance report (2)Identification of the servicing personnel (3)Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4)Testing of any repair for the time as recommended by the manufacturer

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

Findings:

During a facility tour, document review, and interview with the EC on 11/28/17, the EPSS was observed and records were requested and reviewed.

At 10:45 a.m., the facility was observed with three 800 kilowatt diesel fueled generators, each equipped with four lead acid batteries. There were no documentation available for monthly Electrolyte Specific Gravity or conductivity testing for the batteries. Upon interview, the EC confirmed the finding.