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Based on observations, staff interview, and/or documentation on June 25, 2018 at 10:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The south exit discharge from the first floor had a curb drop off. There was not a handicap ramp at the exit discharge from this required means of egress.

Reference 2012 NFPA 101 Section 19.2.7, 7.1.6, S&C 05-38
Reference 2012 NFPA 101 7.1.6 Walking Surfaces in the Means of Egress.
Reference 2012 NFPA 101 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 (6.3 mm), but not exceeding 1/2 in. (13 mm) shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on June 25, 2018 at 10:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The facility utilizes special locking and is completely sprinklered with the exception of the elevator shaft. The facility did not have sprinkler heads in the hydraulic elevator shaft.

Reference 2012 NFPA 101, 2010 NFPA 13 8-15 Elevator Hoistways and Machine Rooms
8.15.5.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit. 8.15.5.2 Automatic sprinklers in elevator machine rooms or at the tops of hoistway shall be of ordinary or intermediate temperature rating. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. 8.15.5.6 Sprinklers shall be installed at the top and bottom of elevator hoistway where elevators utilize polyurethane-coated steel belts or other similar combustible belt material.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on June 25, 2018 at 10:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the stairwell. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Reference 2012 NFPA 101 Section 19.3.5.1, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on June 25, 2018 at 10:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The remote generator annunciator, located at the nurses station, did not provide a signal for loss of : battery charger AC failure when checked.

Reference 2012 NFPA 99: 6.4.1.1.16.2 (Table item O)

2. The facility could not provide documentation that the battery conductance testing was checked monthly.

Reference 2010 NFPA 110 Section 8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.
Reference 2010 NFPA 110 Section 8.3.7.1 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.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.