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STANDARD is not met as evidenced by: Through observation and staff interview the facility failed to install and maintain the Interior Wall and Ceiling Finishes per NFPA 101 Life Safety Code (2012 Edition), section 19.3.3.1 and 10.2. Failure to keep the flame spread rating of Class A or B could harm all occupants, staff, and visitors if a fire occurred.

The CT storage room has missing ceiling tiles.

Life Safety Code section 19.3.3.1 to comply with section 10.2. Section 10.2.3 requires, in part, the interior wall and ceiling finish that is required elsewhere in the Code to be Class A, Class B, or Class C shall be classified based on the test results from ASTM E 84.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Through record review, observation and staff interview of the fire alarm system during the survey, the facility failed to maintain documentation and correct steps needed for Fire Alarm Installation in accordance with National Fire Protection Association (NFPA) 72. Failure to install the fire alarm system per the NFPA 72 requirements could have the potential to harm all occupants, staff, and visitors if the fire alarm system fails to operate as designed if a fire was to occur.

Installation of an unapproved fire alarm panel without proper permitting, approval, and testing by the authority having jurisdiction.

NFPA 72 10.18.1 Approval and Acceptance.
10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring.

10.18.1.2* At the authority having jurisdiction's request, complete information regarding the system or system alterations, including specifications, type of system or service, shop drawings, input/output matrix, battery calculations, and notification appliance circuit voltage drop calculations, shall be submitted for approval.

10.18.1.3 Before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer's published instructions and the appropriate NFPA requirements.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance.

Damaged, lost and missing escutcheon plate through-out the space.

NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Based on observation and staff interviews during the survey, it was determined that the fire resistance rating of smoke barrier walls was not maintained in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all residents in all smoke compartments by allowing the spread of fire and smoke to the adjoining compartments.

The fire barrier walls utilized for subdivisions must uphold a 1-hour fire rating; however, they were discovered to have penetrations in the fire riser and electrical room.

Life Safety Code Section 19.3.2.1 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.1.1 (3) requires, in part, that the space between piping penetrations.

The deficient item was discussed with numerous facility staff during the exit conference.

STANDARD is not met as evidenced by: Based on observation, staff interview, during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems 1999 edition Chapter 3 and 5 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was as evidenced by:

The facility failed to maintain the emergency power system:

Generator was not equipped with a manual stop station. 3-5.5.6 All Level I and Level 2 installation shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises were the prime mover is located outside the building.

NFPA 110-2010 section 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is located outside the building.

The deficient item was discussed with numerous facility staff during the exit conference.