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Based on observation and interview, the facility failed to assuredoors to the laboratory doors were self-closing (NFPA 101, 19.3.2.1)
The findings include:
Observation and interview with the Maintenance Director, on March 13, 2012 at 12:30 p.m. confirmed 1 of 2 doors to the lab, room 136, was not provided with a door closer.

This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

Based on observation and interview, the facility failed to assure the exits were lighted so the the failure of any single lighting fixture (bulb) would not leave the area in darkness (NFPA 101, 7.8.1.4).
The findings include:
Observation and interview with the Maintenance Director, on March 13, 2012 at 1:20 a.m. confirmed the exit discharge outside the rear exit only had 1-single bulb light fixture at the exit discharge.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

NFPA 72, 7-3.2.1 Detector sensitivity shall 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 (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
Based on record review, the facility failed to assure smoke detectors were tested for sensitivity every two (2) years (NPFA 72-7-3.2.1).
The findings include:
Record review with the Maintenance Director, on March 13, 2012 at 11:30 a.m confirmed the last sensitivity testing was performed on 4/30/09.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

NFPA 110, 5-3.1 - The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Based on observation and interview, the facility failed to provide the emergency generator Automatic Transfer Swith location with battery-powered emergency lighting.
The findings include:
Observation and interview with the Maintenance Director, on March 13, 2012 at 1:10 p.m. confirmed the electrical room with the Automatic Transfer Swith was not provided with battery-powered emergency lighting.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

Based on observation and interview, the facility failed to assuredoors to the laboratory doors were self-closing (NFPA 101, 19.3.2.1)
The findings include:
Observation and interview with the Maintenance Director, on March 13, 2012 at 12:30 p.m. confirmed 1 of 2 doors to the lab, room 136, was not provided with a door closer.

This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

Based on observation and interview, the facility failed to assure the exits were lighted so the the failure of any single lighting fixture (bulb) would not leave the area in darkness (NFPA 101, 7.8.1.4).
The findings include:
Observation and interview with the Maintenance Director, on March 13, 2012 at 1:20 a.m. confirmed the exit discharge outside the rear exit only had 1-single bulb light fixture at the exit discharge.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

NFPA 72, 7-3.2.1 Detector sensitivity shall 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 (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
Based on record review, the facility failed to assure smoke detectors were tested for sensitivity every two (2) years (NPFA 72-7-3.2.1).
The findings include:
Record review with the Maintenance Director, on March 13, 2012 at 11:30 a.m confirmed the last sensitivity testing was performed on 4/30/09.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.

NFPA 110, 5-3.1 - The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Based on observation and interview, the facility failed to provide the emergency generator Automatic Transfer Swith location with battery-powered emergency lighting.
The findings include:
Observation and interview with the Maintenance Director, on March 13, 2012 at 1:10 p.m. confirmed the electrical room with the Automatic Transfer Swith was not provided with battery-powered emergency lighting.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on March 13, 2012.