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Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the ceiling. This affected two of three smoke compartments. This could result in the expedited spread of smoke or fire to other areas of the facility.

Findings:

During a tour of the facility with staff on 9/13/17, the ceilings were observed.

1. At 2:59 p.m., there was an approximately 2 inch by 3 inch penetration in the ceiling, in the Mechanical and Engineering Room. The finding was confirmed by the Environmental Services staff.

2. At 3:16 p.m., there was an approximately one inch diameter in the ceiling around an antenna wire and an electrical conduit, in the Board Room. When interviewed, the Environmental Services staff stated that they were not aware of the penetration in the ceiling.

Based on observation, the facility failed to maintain the battery back-up combination emergency exit sign with lights. This was evidenced by the emergency lights on the exit signs that failed to illuminate. This affected two of three smoke compartments, and could result in a failure of normal lighting.

NFPA 101 Life Safety Code, 2012 Edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 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, except as otherwise permitted by 7.9.3.1.1(2).
(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 11?2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 11?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11?2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

During a tour of the facility with staff on 9/13/17, the battery back-up combination emergency exit sign with light was observed.

1. At 2:55 p.m., a battery back-up combination emergency exit sign with light located between Room 106 and the Lobby was observed. The emergency light failed to illuminate when the Environmental Services staff pushed the test button.

2. At 3:05 p.m., a battery back-up combination emergency exit sign with light located in Emergency Room 1 by Bed 2 was observed. The emergency light failed to illuminate when the Environmental Services staff pushed the test button.

Based on observation, the facility failed to maintain the fire alarm system notification devices. This was evidenced by outdated batteries for the Fire Alarm Control Panel (FACP). This affected three of three smoke compartments, and could result in a delayed notification of a fire.

NFPA 101, Life Safety Code, 2012 Edition
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3, unless otherwise modified by the following:
(1)*In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
(2) Where visual devices have been installed in patient sleeping areas in place of an audible alarm, they shall be permitted where approved by the authority having jurisdiction.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Table 14.4.5 Testing Frequencies
(c) Sealed lead-acid type 6d
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed.)

Findings:

During a tour of the facility with staff on 9/13/17, the Fire Alarm Control Panel (FACP) batteries were observed.

At 1:40 p.m., two sealed-lead acid batteries in the FACP located in the Mechanical and Engineering Room were outdated. The dates marked on the batteries were 3/12/12. The findings were acknowledged by the Environmental Services staff.

Based on observation, document review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documented monthly visual inspections of the sprinkler components. The failure to inspect the sprinkler components could result in a malfunction in the event of a fire. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.3.3 Waterflow Alarm Devices.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Findings:

During a tour of the facility, and interview with staff on 9/13/17, the sprinkler components were examined, and inspection documents were requested.

1. At 1:44 p.m., there was no documented evidence of monthly visual inspections of the sprinkler gauges and valves as required. No documented evidence was provided for monthly visual inspections.

2. At 1:50 p.m., the Environmental Services staff stated that the gauges were inspected quarterly with the sprinkler flow test and they were not aware of the required monthly inspection.

Based on observation, the facility failed to maintain their doors. This was evidenced by a door that failed to latch. This could allow the spread of smoke and fire in the event of a fire. This affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protective's, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Fire Windows, 2010 Edition
5.2.14.1 Self-closing devices shall be kept in working condition at all times.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Findings:

During a tour of the facility with staff on 9/13/17, the doors in the facility were inspected.

At 2:52 p.m., the door to Room 109 was equipped with a self-closing device that failed to latch when fully opened and released. The finding was confirmed by the Environmental Services staff.