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Based on a review of documentation, igt was determined that the facility has failed to conduct fire drills in conformance with NFPA 101 Section 19.7.1.2 guidelines.

Findings are as Follows: :

NFPA 101 Section 19.7.1.2 States: Fire drills shall be conducted quarterly on each shift under varing conditions across the full spectrum of the shift.

The fire drills conducted on the third shifts for the past four calendar quarters starting in March 2014, indicate that the fire drills were conducted between 4:30AM and 4:50AM.

Fire drills need to be performed once per quarter for each shift, across the full spectrum of the shift.

Based on surveyor observation with facilities staff, during the Life Safety Code tour, it was determined that the facility failed to provide sprinkler coverage in the elevator machine rooms on the north and south units of the Beazley building ID# 4.

Findings are as follows:

Surveyor observation during the Life Safety Code tour with facility staff on February 5, 2015, revealed the elevator machine rooms located on the north and south units of Beazley building lacked sprinkler protection.