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NFPA 72, 1-5.6. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Based on observation it was determined the facility failed to protect the fire alarm panel from fire.

Findings include:

Observation of the fire alarm panel in the locked work room on 4/30/12 revealed the room did not have a smoke detector to protect the panel.


The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

NFPA 72, 1999 edition

2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).2-3.5.1*In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

Based on observation, it was determined the facility failed to install 2 of 64 smoke detectors away from airflow registers.

The findings included:

1. Observation on 4/30/12 at 10:06 A.M. of the resident central bath located on the second floor revealed the smoke detector was too close to the exhaust vent.

2. Observation of the phone room by the purchasing department on 4/30/12 at 10:17 A.M. revealed the smoke detector to close to the supply air vent.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

Based on observation, the facility failed to maintain fire walls.

The findings included:

1. Observation of the mechanical room by the purchasing department on 4/30/12 at 10:25 A.M. revealed the fire wall was not sealed to the roof deck.

2. Observation of the 200 hall on 4/30/12 at 2:20 P.M. revealed a penetration above the fire doors by the private office.

3. Observation of the 100 hall on 4/30/12 at 2:30 P.M. revealed a penetration above the fire wall by room 105.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 edition
Chapter 6 6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Based on document review and interview, it was determined the facility failed to document testing of the generator battery.

The findings included:

During the document review in the conference room on 4/30/12 from 11:45 A.M. until 2:15 P.M. the facility failed to provide documentation of electrolyte levels for the generator battery.

During an interview with the maintenance man in the fire panel room on 4/30/12 at 3:00 P.M. The surveyor asked the maintenance manager if he had maintenance free batteries and he replied, "No". When asked if he checked the battery fluids, he stated, "once in a while, but we don't document it."

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

Based on observation, it was determined the facility installed an alcohol based hand rub dispenser adjacent to an ignition source.

The findings included:

Observation of the dishwasher room on 4/30/12 at 2:50 P.M. revealed an alcohol based hand rub dispenser installed adjacent to an electrical switch.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

NFPA 72, 1-5.6. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Based on observation it was determined the facility failed to protect the fire alarm panel from fire.

Findings include:

Observation of the fire alarm panel in the locked work room on 4/30/12 revealed the room did not have a smoke detector to protect the panel.


The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

NFPA 72, 1999 edition

2-3.5 Heating, Ventilating, and Air-Conditioning (HVAC).2-3.5.1*In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

Based on observation, it was determined the facility failed to install 2 of 64 smoke detectors away from airflow registers.

The findings included:

1. Observation on 4/30/12 at 10:06 A.M. of the resident central bath located on the second floor revealed the smoke detector was too close to the exhaust vent.

2. Observation of the phone room by the purchasing department on 4/30/12 at 10:17 A.M. revealed the smoke detector to close to the supply air vent.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

Based on observation, the facility failed to maintain fire walls.

The findings included:

1. Observation of the mechanical room by the purchasing department on 4/30/12 at 10:25 A.M. revealed the fire wall was not sealed to the roof deck.

2. Observation of the 200 hall on 4/30/12 at 2:20 P.M. revealed a penetration above the fire doors by the private office.

3. Observation of the 100 hall on 4/30/12 at 2:30 P.M. revealed a penetration above the fire wall by room 105.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 edition
Chapter 6 6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Based on document review and interview, it was determined the facility failed to document testing of the generator battery.

The findings included:

During the document review in the conference room on 4/30/12 from 11:45 A.M. until 2:15 P.M. the facility failed to provide documentation of electrolyte levels for the generator battery.

During an interview with the maintenance man in the fire panel room on 4/30/12 at 3:00 P.M. The surveyor asked the maintenance manager if he had maintenance free batteries and he replied, "No". When asked if he checked the battery fluids, he stated, "once in a while, but we don't document it."

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor at the exit interview on 4/30/12.