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STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 7.1.10.1This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. This was evidenced by the following:

Storage in exit from SPD to loading dock blocking the means of egress.

The Director of Maintenance acknowledged the condition of the door during the time of the tour.

7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

STANDARD is not met as evidenced by: Based observation and staff interviews during the tour of the facility it was determined a lack of Emergency Lighting for the Means of Egress in accordance with Life Safety Code 101 section's 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:

Broken E-light in ER 20

The Director of Maintenance acknowledge the required emergency lighting requirement during the tour of the facility.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11through 43
(2) Underground and limited access structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed-egress locks
(5) Stair shafts and vestibules of smokeproof enclosures, for which the following also apply:
(a) The stair shaft and vestibule shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment.
(b) The standby generator shall be permitted to be used for the stair shaft and vestibule emergency lighting power supply.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following.

1)Facility failed to provide proper exit signage in the hall between OR 21 and OR 6 missing.

2)No direction on exit sign adjacent to OR 15.

The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

1)Hazardous area corridor doors were not arranged to be self-closing, as required

The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility.
Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section) 6.2.2.3 This deficient practice could affect all residents and staff in the main smoke compartment it should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

Room 3405 being used for storage while not being rated NFPA 101 (2012) 6.2.2.3

The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility.

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.
Room 3405 being used for storage while not being rated NFPA 102 (2012) 6.2.2.3

STANDARD is not met as evidenced by: During the facility tour with staff, it was discovered that the fueled fired appliances were not installed as required by code. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate effectively due to non-code compliant maintenance. This was evidence by the following;

During facility tour with staff, it was discovered that the fueled fired appliances were not tethered to the wall as required by code.

The Maintenance Director acknowledge the lack of servicing of the system and the lack of tethering to the wall.
NFPA 54-2012 Fuel and gas Code 9.6.1.2

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with 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 in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following:

Missing two quarterly visual inspections. First and third quarter missing NFPA chapter 25.

The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with 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 in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.
1) Loaded Missing two quarterly visual inspections. First and third quarter missing NFPA chapter 25
2) heads in main entry
3) Damaged head adjacent to OR 15, head outside men's locker room.
4) No tag on the sprinkler riser.
5) Sprinklers too close together SPD

The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5
NFPA 13 8.5.3.4.2

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following.

At the time of the survey no documentation or records that all fire extinguishers through-out the facility were subjected to maintenance at intervals of not more than 1 year, monthly checks, at the time of hydrostatic test, or when specifically indicated by an inspection.

The Maintenance Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers

NFPA 13 8.5.3.4.2 STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following:

At the time of the survey no documentation or records that all fire extinguishers through-out the facility were subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

The Maintenance Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following.

At the time of the survey no documentation or records that many fire extinguishers through-out the facility were subjected to replacement

The Maintenance Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following:

Corridor doors were not maintained to close and positively latch, as required, rooms 4402, 4403, 3422, 1119 and Environmental Services entry door.

The Director of Maintenance acknowledge the corridor door condition during the facility tour.

The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and latching.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.7.3 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Unsealed penetrations at smoke barrier walls in the service corridor and PT hall were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required.

The Maintenance Director acknowledge the penetrations during a tour of the facility.

Life Safety Code Section 19.3.7.3 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 ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between piping penetrations.

STANDARD is not met as evidenced by: Based on observation during walk through.
Excessive gap around door in rooms 5409, 5403, 5405, 5418, 5419, 4405, 2311.

The Director of Maintenance acknowledge the corridor door condition during the facility tour.

The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain electrical equipment in accordance with National Fire Association 70, National Electrical Code. This deficient practice could affect all residents on the sixth floor smoke compartments due to increased potential hazards of electrical fire. This was evidence by the following:
The facility failed to maintain electrical equipment
1) During the walk-through of the facility, the 3rd floor supply room panel would not close and latch.
2) Missing strain relief on equipment OR 14.

The Director of Maintenance acknowledged the electrical hazard during a tour of the facility.

NFPA 70, National Electrical Code Article 370-25. Covers and Canopies in completed installations, each box shall have a cover, faceplate, or fixture canopy.

STANDARD is not met as evidenced by: Based on record review and 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 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.
This was evidenced by the following.

At the time of the survey no records were available to verify testing and recording of battery
conductance testing in connection with the emergency power supply system (emergency generator) monthly.

The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator.

NFPA 110, Section 8.3.7. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.