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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 and afternoon hours of 1/12/15, it was observed that the building is of 5-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.


NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations and confirmed by staff, the facility failed to maintain corridor doors in accordance with 19.3.6.3.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/12/15 revealed that corridor doors to resident rooms #5 and #10 have a 24" by 1/2 inch split in the door face.

This was acknowledged by staff during the facility tour and at the exit conference.

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 and afternoon hours of 1/12/15, it was noted that the linen chute is equipped with a non-rated door open to the second floor level corridor.


NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

The following items were observed regarding Hazardous Areas:

1) While performing the building tour on the afternoon of 1/12/15 , it was observed that the two doors to the first floor kitchen are not equipped with functioning self closing devices. Each door is equipped with self closing hinges but they are not working properly.

2) While performing the building tour on the afternoon of 1/12/15 , it was observed that the doors to the first floor kitchen leading to the dinning room are not equipped with automatic latching devices nor are the doors smoke tight. The doors are 32 inch wide pivoted type doors, and are neither equipped with door stops nor are they equipped with self latching devices.

3) While performing the building tour on the afternoon of 1/12/15 , it was observed that the two corridor doors to the basement boiler room are not equipped with functioning self closing devices. The doors are equipped with a weighted chain system however it is not working properly.

4) While performing the building tour on the afternoon of 1/12/15 , it was observed that one of the two boiler room corridor doors is equipped with a 24" x 20" louver.

5) While performing the building tour on the afternoon of 1/12/15 , it was observed in the boiler room ceiling has several holes exposing the wood joists in the ceiling. These holes measure 36 " x 72 ", a 24 " x 24 " hole below the kitchen sink, a 6 " diameter hole below the first floor bathroom , and a 3' x 3 ' hole

6) While performing the building tour on the afternoon of 1/12/15 , it was observed that the corridor ceiling has two holes measuring 4" x 6" and 4" x 8" above the three oil tanks (250 gallons each).

This was acknowledged by staff during the facility tour and at the exit conference.

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:
Observations while touring the facility during the morning and afternoon hours of 1/12/15, it was revealed that;

1. The front, center and rear stairs are all enclosed with less than one hour rated construction on the first, second and third floor levels.

2. The first floor level resident rooms 1 thru 4, second floor level resident rooms 5, 6, 7,13, 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 does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

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

THE FINDINGS INCLUDE:

Observations made during the morning and afternoon hours of 1/12/15 while touring the facility, revealed that the front, center, and rear stairs all narrow to 33 inches in width.


NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

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 1/12/15 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 does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

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

THE FINDINGS INCLUDE:

Observations made on 1/12/15 revealed corridors narrow to 40" and 30" in width on the first, second, and third floor levels.


NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

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 1/12/15 revealed all of the resident room doors to the corridor on the first and second floors are 30" wide.



NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

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 sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.

THE FINDINGS INCLUDE:

Observations made on 1/12/15 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 does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on record review and confirmed by staff interview, the facility failed to ensure that battery powered emergency lights are maintained and tested as required. Section 7.9.3 requires a functional test to be conducted at 30-day intervals for not less than 30 seconds and an annual test for not less than 1-1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

THE FINDINGS INCLUDE:

Record review on the morning of 1/12/15 revealed:

1. The battery powered emergency lights are not tested monthly. The only documented test conducted within the previous 12 months was conducted during September 2014.

2. There is no documentation that an annual 1-1/2 hour test was conducted on any of the devices during the previous 12 months.

This was acknowledged by staff during the facility tour and at the exit conference.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

While conducting document review provided on 1/13/15, the following was noted:

First shift (8:00 A.M. - 4:00 P.M.) fire drills were conducted on:
- 7/18/14, (no time documented for drill), and
- 3/13/14, (no time documented for drill)

Second shift (4:00 P.M. - 12:00 P.M.) fire drills were conducted on:
- 8/5/14 at 5:00 P.M.,
- 4/5/14, (no time documented for drill), and
- 1/22/14, (no time documented for drill)

Third shift (12:00 P.M. - 8:00 A.M.) fire drills were conducted on:
- 9/19/14 at 6:00 A.M.,

1. The facility failed to conduct first, second and third shift fire drills at least quarterly as required.
- There are no first shift fire drills conducted during the second and fourth quarters of 2014.
- There are no second shift fire drills conducted during the fourth quarter of 2014.
- There are no third shift fire drills conducted during the first, second and fourth quarter of 2014.

2. The facility failed to accurately document first and second shift fire drills. First shift fire drills conducted during the first and third quarters failed to note the time the fire drill was conducted. Second shift fire drills conducted during the first and second quarters failed to note the time the fire drill was conducted.

This was acknowledged by staff during record review and at the exit conference.

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. Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. Section 9.6.1.7 requires fire alarm system to have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 and NFPA 72.

NFPA #72, Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided that includes the following information regarding tests and all the applicable information requested in Figure 7.5.2.2.
Section 7.3.2 and Table 7.3.2(20) requires off-premises transmission equipment to be tested quarterly. Section 7.2.2 and Table 7.2.2(9)d. requires the transmission of signals to off-premises location to be tested by actuating an initiating device and verifying the receipt of alarm signal at the off-premises location.

THE FINDINGS INCLUDE:

After reviewing the vendor's annual test forms dated 9/4/14 and 8/29/13 it was noted that the facility was not conducting the required testing in accordance with NFPA 72. Documenation provided failed to substantiate the annual testing of the battery charger, the semi-annual load voltage test and the quarterly test of the off-premises transmission equipment.

This was acknowledged by staff during record review and at the exit conference.

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises and in accordance with NFPA 13.

NFPA 13-1999 Edition, Section 5.1.1(1) requires sprinklers to be installed throughout the premises.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/12/15 revealed automatic sprinklers are not provided in the first floor level housekeeping (toilet paper) closet adjacent to the Great Room, the second floor level linen closet next to room # 14, and the third floor level storage area next to room # 22.

This was acknowledged by staff during the facility tour and at the exit conference.

A review of the facility's automatic sprinkler system inspection reports made available on 1/12/15 indicated that the facility failed to assure the automatic sprinkler system is maintained, tested and inspected per the requirements of NFPA 25 1998 Edition.

NFPA 25 Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. NFPA #25 Chapter 6 Section 6-2 Inspections and Section 6-4 Maintenance require the following:
1) Section 6-2.1: The water level and the condition of the water in the tank shall be inspected monthly.
Exception: Tanks equipped with supervised water level alarms that are connected to a constantly attended location shall be permitted to be inspected quarterly.
2) Section 6-2.4: The interior of the tank shall be inspected every 5 years.
Exception No. 1: The interior of steel tanks without corrosion protection shall be inspected every 3 years.
Exception No. 2: The interior of pressure tanks shall be inspected every 3 years.
3) Section 6-2.7: The air pressure in pressure tanks shall be inspected monthly.
Exception: Pressure tanks that have their air pressure source supervised in accordance with NFPA 72, National Fire Alarm Code®, shall be permitted to be inspected quarterly.
4) Section 6-4.3: Sediment shall be drained or flushed from the tank semiannually.
5) Section 6-4.8: All tank drain valves shall be opened fully and closed annually.

FINDINGS INCLUDE:

During the survey conducted on 1/12/15 and 1/13/15, there was no documentation available to substantiate that any inspection/maintenance of the automatic sprinkler system's pressurized water storage tank has been performed in accordance with NFPA 25. The following items were noted as deficient, but are not limited to:

1) The water level and the condition of the water in the tank is inspected monthly.
2) The interior of the pressurized steel storage tank has been inspected within the past three (3) years.
3) The air pressure within the pressurized tank is inspected monthly.
4) The sediment is drained or flushed from the tank semi-annually.
5) All of the tanks valves are being fully opened and closed on an annual basis.

This was acknowledged by staff during the facility tour and at the exit conference.

Based on record review and confirmed by staff interview, the kitchen exhaust system is not inspected and cleaned as required. NFPA 96, Section 8.3.1 Requires the entire kitchen exhaust system be inspected by a properly trained, qualified, and certified company or person(s) semi-annually. Section 8.3.1.1 requires exhaust systems found to be contaminated with deposits from grease-laden vapors during inspection, to be cleaned by a properly trained, qualified, and certified company or person(s).
Section 8.3.1.2 requires a certificate showing the date of inspection or cleaning to be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

THE FINDINGS INCLUDE:

Observation and records reviewed on the morning of 1/12/15 revealed that the kitchen range exhaust system installed over the ovens is not inspected semi-annually. According to the inspection sticker attached to the kitchen hood, the kitchen range exhaust system was last inspected by a contractor on 12/20/13. More than twelve (12) months have passed since the last inspection.

This was acknowledged by staff during the facility tour and at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure.

THE FINDINGS INCLUDE:

During the afternoon of 1/12/15, while conducting the facility tour, temporary type construction lights were found in the following areas:

1) The third floor corridor that leads to the medical records storage area.
2) The medical record storage room.

As a result of the findings, the facility is found to be non-compliant with NFPA 70 National Electrical Code 1999 Edition Article 400-8.

This was acknowledged by staff during the facility tour and at the exit conference.