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One-story buildings of Type II (000) construction are required to be protected by an automatic sprinkler system. Without a sprinkler system, Type II (111) construction is required. 19.1.6.2 through 19.1.6.7.

The facility failed to provide a construction type that met the requirements of the Life Safety Code.

Observation determined the steel I-beams and columns were not protected as a one-hour fire rated assembly.

Failure to meet the requirements of building construction type increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

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. 9.6.1.3. 2010 NFPA 72, 14.1.1

The facility failed to test the fire alarm system as required.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 10/10/2024. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

Fire extinguishers shall be manually inspected when initially placed in service and thereafter either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 19.3.5.12, 9.7.4.1, NFPA 10 7.2.1.1, 7.2.1.2

The facility failed to inspect and maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Record review and observation determined no documentation was available to indicate inspections of portable fire extinguishers throughout the facility had been completed during October, November, and December 2024.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected all portable fire extinguishers in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) No fire drills were conducted on the Day Shift during the first and second quarters in the past year.

2) No fire drills were conducted on the Night Shift during the first, second, third and fourth quarters in the past year.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected six (6) of twelve (12) drills in the past year.

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 Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

The facility failed to inspect and test fire rated door assemblies throughout the facility.

Review of documentation and interview with staff determined all fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

The deficiency affected numerous fire rated door assemblies throughout the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.2, 8.4.2.3

Review of generator test records and interview with staff:

1) Did not indicate the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 125 kW diesel generator loaded the generator to at least 30% (37.5 kW) of the nameplate rating. The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer's recommended temperature during the required monthly exercises.

2) Determined the monthly tests of the emergency generator were not conducted for all months during the past year.

Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.