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Based on observation, the facility failed to conduct the monthly visual inspections of all exit signs. This affected one of one smoke compartments and could result in delayed egress in the event of an emergency evacuation.

NFPA 101 Life Safety Code, 2012 edition
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.


Findings


During document review with staff members on 5/04/17, the records for the monthly visual inspections of the facility exit signs were requested.

1. At 11:22 a.m., no documents were provided for the monthly visual inspection of the exit signs were requested. During an interview, staff stated the facility had recently started the monthly visual inspections of the exit signs, but had not finished..

Based on document review and staff interview, the facility failed to maintain the automatic sprinkler system as evidenced by not conducting the monthly visual inspections of the automatic sprinkler system. This affected one of one smoke compartment and could result in the failure of the sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 edition
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.
9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.
13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

Findings

During document review with staff members on 5/04/17, the documents for the visual inspection of the automatic sprinkler system were requested.

1. At 11:34 a.m., no documents were provided for the monthly visual inspections of the automatic sprinkler system. During an interview, staff stated the sprinkler system was tested quarterly. During the quarterly test all valves and gauges are inspected.