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Based on observation during the course of the survey, it was determined the facility failed to maintain the horizontal exit used as a fire barrier separating building construction types in accordance with NFPA 101, 19.2.8 including 7.8 and 7.10.7.2. The following evidenced this:

Photoluminescent Exit signs are not UL listed so unable to determine if they would operate for 90 minutes.

7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

7.10.7.2* Photoluminescent Signs. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source, as determined by the authority having jurisdiction. The charging light source, shall be of a type specified in the product markings.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within affected smoke compartments. This item was discussed during the survey and again during the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain hazardous areas in accordance with NFPA 101, 39.3.2. The following evidenced this:

Second floor mechanical/boiler room, has no fire rated door and has penetrations through fire rated wall.

39.3.2.1* General

Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.7.

39.3.2.2* High Hazard Contents Areas

High hazard contents areas, as classified in Section 6.2, shall meet all of the following criteria:
The area shall be separated from other parts of the building by fire barriers having a minimum 1-hour fire resistance rating, with all openings therein protected by self-closing fire door assemblies having a minimum 3/4-hour fire protection rating.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1. Electrical room on third floor has a pipe going through the smoke wall that is not sealed.

Life Safety Code Section 19.3.2.1.2, in part, where sprinkler option of Section 19.3.2.1 is used as hazardous area safeguard, smoke partitions must be in accordance with Section 8.4. Section 8.4, in part, smoke partitions shall be provided to limit the transfer of smoke.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the affected compartments. Deficient items were discussed with the maintenance director during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

1) No documentation of annual or semi-annual fire alarm inspection reports was available during time of inspection.

Life Safety Code section 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 section 14.4.5 requires, in part, testing shall be performed in accordance with the schedules in Table 14.4.5.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

Sprinkler head in ER has a hole around the excutcheon which pentrates the ceiling.

Life Safety Code Section 19.3.7.3 to comply with section 8.5. Section 8.5.6.2, in part, penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. Deficient items were discussed with the maintenance director during the exit conference.