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Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Records review determined annual testing of the battery-powered emergency lighting was not documented.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights in the facility.

Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.3, 4.6.12.4

Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the supply registers of a forced air heating or cooling system and shall be installed outside of the direct airflow from those registers. Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the tip of the blade of a ceiling-suspended (paddle) fan. NFPA 72 29.8.3.4(6), 29.8.3.4(7).

The facility failed to ensure smoke alarms and smoke detectors were in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined a battery operated smoke alarm in the Beauty Shop was located within a 36 in. horizontal path from the tip of the blade of a ceiling-suspended fan.

Failure to install smoke alarms and smoke detectors as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous smoke alarms and smoke detectors in the facility. The smoke alarms and smoke detectors serve the entire facility.

Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors must be enclosed with construction having a fire resistance of at least one hour. 19.3.1

The facility failed to ensure all vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour.

Observation determined:

1)The corridor door to the south stair enclosure on the 1st Floor had multiple unsealed penetrations.

2) The corridor door to the center stair enclosure on the 1st Floor had multiple unsealed penetrations.

Failure to protect vertical openings with construction having a fire resistance rating of at least one hour increases the risk of death or injury due to fire.

This deficiency affected two (2) of three (3) stair enclosures connecting the first floor and the basement.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and self-closing doors.

Observation determined the east corridor door to the Laundry Room failed to self-close and latch.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 12/01/2016. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 13.2.7.1, 13.3.2.1.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and interview with staff determined the control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.6

The facility failed to conduct fire drills as required.

Fire drill records review determined the last four (4) fire drills for the PM shift occurred at 2:45 pm, 2:45 pm, 3:00 pm and 2:35 pm.

Fire drills are required to be conducted under varied conditions. The condition of the time of the day was not varied. Four (4) fire drills in the past year all occurred at times within 25 minutes of each other in an 8 hour shift.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected four (4) of twelve (12) drills in the past year.