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Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The fire wall between the business occupancy and health care section is incomplete due to holes in barrier - holes are located above ceiling in room #13.

NFPA 101, 19.1.6, 19.1.3.5, 8.2.1.3

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are no fire protective enclosures for recessed light fixtures - located throughout facility.

2. There are no ceiling fire dampers at duct penetrations of rated roof/ceiling assembly - alternative to ceiling fire dampers, at time of construction, is missing or in disrepair.

3. There is a combustible, wood deck, structure in the required means of egress path - located at the exit discharge on westside of building.

NFPA 101, 19.1.6.1, 19.1.6.2 through 19.1.6.7

This deficiency affects one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are wood studs used to support suspended ceiling grid - construction type doesn't permit the use of combustible members in the rated roof/ceiling assembly - located in roof/ceiling assembly above office #20.

2. There are no ceiling fire dampers in mechanical inlets/outlets throughout the facility - alternative to ceiling fire damper assemblies are missing or in disrepair at duct penetrations of ceiling assembly - located in resident rooms and areas near office #20.

3. There are no fire protective enclosures for recessed light fixtures in office #20.

4. There are holes in the rated roof/ceiling assembly of office #20.

NFPA 101, 19.1.6.5

Note: The facility is designed to be Type II protected construction without an automatic sprinkler system.


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are holes in the rated roof/ceiling assembly of panel room - located at rear lobby.

NFPA 101, 19.1.6.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are chairs stored in the means of egress near the nurse's station - located near area reserved as a sitting area.

NFPA 101, 19.2.1, 7.1.10.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are travel distances exceeding fifty feet to exit access doors from interior courtyard.

NFPA 101, 19.2.6, 7.6

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The exit discharge path extends near an embankment with no guardrail between deep and sloped area adjacent to sidewalk - located near room B108. The slope perpendicular to the direction of travel exceeds 1 in 48.

NFPA 101, 19.2.7, 7.1.6.3

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no exit discharge lighting to illuminate exit path to publicway - exit discharge near room #13.

NFPA 101, 19.2.8

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no exit discharge lighting to illuminate exit path to publicway - exit discharge near room B108.

2. Exit discharge path serving activity gym and acute care unit is not equipped with emrgency lighting to cover entire egress path to publicway.

NFPA 101, 19.2.8, 7.8.1.3

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The battery powered light is not functioning in corridor area near room #7.

2. The exit discharge is not complete to publicway with emergency lighting - existing lighting, near room #8, will not cover path to publicway.

NFPA 101, 19.2.9.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is inadequate exit directional signage for courtyard near dayroom - direction to exit is not obvious beyond exit access gate from courtyard.

NFPA 101, 19.2.10.1, 7.10.1.5.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Gas fired water heater room is not one hour enclosed or equipped with sprinkler.

NFPA 101, 19.3.2.1, 8.7.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are holes in the enclosing wall of gas-fired water heater room - room contains main sprinkler riser.

NFPA 101, 19.3.2.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is no electrical supervision of main sprinkler control valves located in outside valve pit.

NFPA 101, 19.3.5, 9.7.2.1

This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is a wedge under door to room #10.

NFPA 101, 19.3.6.3.10

2. Dutch door to discharge room is not equipped with self-closing device on upper leaf - doors are not arranged to close and latch as a unit.

NFPA 101, 19.3.6.3.13

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is a wedge under door to room #13.

2. There is a wedge under door to janitor's closet - located beside nurse's station.

NFPA 101, 19.3.6.3.10

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are kickstops mounted on cross corridor smoke barrier doors - located near rooms B116/B102 & C101.

NFPA 101, 19.3.7.6, 19.3.7.8, 19.3.7.9

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. mobile air conditioning unit is connected to a quadruplex receptacle - device listing requires a single use outlet. Unit is located in electronic equipment room near nurse's station.

NFPA 101, 19.5.1.1, 9.1.2
NFPA 70, 2011 Ed

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The duct penetrations of required smoke barrier are not equipped with smoke dampers - located at main mechanical room.

2. There are no air handler shutdown switches located at supervised station.

NFPA 101, 19.5.2.1, 9.2.1,
NFPA 90A , 2012 Ed

This deficiency affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Duct smoke detector sampling tubes are covered with dust - detectors shall be maintained in accordance with manufacturer's installation instructions.

NFPA 101, 19.5.2.1, 9.2
NFPA 90A, 2012 Ed

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are no air handler shutdown switches located at a supervised station.

NFPA 101, 19.5.2.1, 9.2

This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are high temperature, exposed element, portable space heaters observed in the following rooms:

1. room PC 116

2. room PC 110

3. under desk in laboratory office

NFPA 101, 19.7.8

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The generator annunciator panel did not indicate generator switch in the off position at time of arrival to facility.

2. The generator annunciator panel failed to indicate emergency power system supplying load during loss of normal power to the automatic transfer switch.

NFPA 101, 19.5.1, 9.1.3
NFPA 99, 6.4.1.1.17, 6.4.1.1.17.5

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on February 22, 2017 at approximately 9:00AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The emergency power system test were not documented for review - there were no thirty minute monthly load test or weekly inspection documents available for review.

2. There is no remote manual stop switch for emergency generator - switch shall be located remote from generator enclosure.

NFPA 101, 19.5.1, 9.1.3
NFPA 110- 2010 ed, 8.4.1,
NFPA 99, 2012 ED, Section ,

This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.