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Based on observations and confirmed by staff, the facility failed to ensure that the building is of a conforming construction type. Section 19.1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is fully sprinklered it may be of Type II (111) construction.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 2/06/12, it was observed that the building is of 3-story Type V (000) construction. The building is not fully sprinklered as required. See ID Prefix Tag K 056.

This was acknowledged by staff during the exit interview.

Based on observations and confirmed by staff, the facility failed to maintain corridor doors in accordance with 19.3.6.3. The Centers for Medicare & Medicaid Services S&C-07-18 states "In a smoke compartment that is fully sprinklered, a gap between the face of a corridor door and the door stop should not exceed ?-inch".

THE FINDINGS INCLUDE:

- Observations while touring the facility on 2/7/12 revealed that doors to resident rooms: #10 and #13 have a 12" by 1/2 inch split in the door face.

This was also observed by the physical plant director and reviewed during a summary of survey findings with the physical plant director and the facility's owner.

Based on observations and confirmed by staff, the facility failed to ensure that the linen chute is enclosed as required. Section 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Section 8.2.5.2 states openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance.

THE FINDINGS INCLUDE:

- Observations while touring the facility during the morning & afternoon hours of 02/07/11, it was revealed that the linen chute is equipped with a non-rated door open to the second floor level corridor.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are enclosed with the required 1-hour fire resistant construction.

THE FINDINGS INCLUDE:

1. The front, center and rear stairs are all open to the first, second and third floor levels.

2. The first floor level resident rooms 1 thru 4, second floor level resident rooms 5, 6 and 7 and resident rooms 13, 14, and 15 and the third floor level resident rooms 17 thru 20 are all open to a stair and all are equipped with 1-3/8" thick, six panel non-rated doors.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on observation, the stairways and smokeproof towers used as exits are not in compliance with section 7.2.2.2.1 of the NFPA 101. Minimum with of stairs shall be 44 inches.

THE FINDINGS INCLUDE:

- Observations made during the morning & afternoon hours of 2/7/12 while touring the facility, revealed that the front, center, and rear stairs all narrow to 33 inches in width.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on observations exit egress is not constructed or maintained as required. Section 19.2.5.9 states every corridor shall provide access to not less than two approved exits in accordance with section 7.4 & 7.5 without passing through any intervening rooms or spaces other than corridors of lobbies.
Section 7.1.5 states that means of egress shall be designed and maintained to provide headroom as provided in other sections of this Code and shall be not less than 7 ft 6 in. with projections from the ceiling not less than 6 ft 8 in. nominal height above the finished floor. Headroom on stairs shall be not less than 6 ft 8 in. and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread.

THE FINDINGS INCLUDE:

Observations made on 2/7/12 revealed the following:
- The corridors narrow to 40" and 34" wide on the first, second, and third floor levels.
- The height of the ceiling above the floor reduces to 6' on third floor, second floor and basement levels.
- Corridor wall light fixtures project 5" off the wall at 69" above the floor level.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on observations and confirmed by staff, the facility failed to ensure that exit egress corridors are constructed & maintained at 48" in width.

THE FINDINGS INCLUDE:

Observations made on 2/7/12 revealed corridors narrow to 40" & 30" in width on first, second, and third floor levels.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on observations and confirmed by staff, the facility failed to ensure that the minimum clear width of doors in the means of egress is no less than 32 in.

THE FINDINGS INCLUDE:

Observations made on 2/7/12 revealed all of the resident room doors to the corridor are 30" wide.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on observations and confirmed by staff, the facility failed to provide egress doors as required. Section 19.2.5.9 states every corridor shall provide access to not less than two approved exits in accordance with section 7.4 & 7.5 without passing through any intervening rooms or spaces other than corridors of lobbies.

THE FINDINGS INCLUDE:

Observations made on 2/7/12 revealed the following:
- the access to the corridor from resident room #3, discharges through resident room # 2, prior to gaining access to the corridor, and
- the access to the corridor from the first floor level group (meeting) room, discharges through one of the living rooms, prior to gaining access to the corridor.

NOTE: This item will meet the FSES upon the completion of ID Prefix Tag K 056 and does not require corrective action.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

- Records reviewed on the morning of 2/7/12 revealed that there was no documentation available substantiating that the sensitivity of smoke detectors has been checked as required.
This was confirmed by the Physical Plant Director and reviewed during the summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler protection is provided in accordance with NFPA 13. NFPA 13 section 5.13.8.1 states sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft in width. Section 5.13.8.2 states sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handled.

THE FINDINGS INCLUDE:

- Observations while touring the facility on 2/7/12 revealed automatic sprinklers are not provided under the buildings' exterior wood roof over the ramp. The roof is 34' long by 5' 6" and 12' wide.

This was confirmed by the Physical Plant Director and reviewed with the owner during the summary of survey findings.

Based on observations, the facility failed to ensure that the main sprinkler control valve is electrically supervised.

THE FINDINGS INCLUDE:

- Observations while touring the facility on 2/7/12 revealed that the wet type sprinkler system control valve, located below the storage tank, is not equipped with a tamper switch. During an interview with the facility's physical plant director, he said the tamper switch had been removed due the increased number of false alarms created by the switch's location being affected by rising ground water levels.

This was confirmed by the Physical Plant Director and reviewed with the owner during the summary of survey findings.