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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 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 test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

At a minimum, this quick check or inspection shall include verification of the following:

1) The extinguishing system is in its proper location.
2) The manual actuators are unobstructed.
3) The tamper indicators and seals are intact.
4) The maintenance tag or certificate is in place.
5) No obvious physical damage or condition exists that might prevent operation.
6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
7) The nozzle blowoff caps, where provided, are intact and undamaged.
8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

If any deficiencies are found, appropriate corrective action shall be taken immediately. Where the corrective action involves maintenance, it shall be conducted by a trained service technician. Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspection of the wet chemical extinguishing system in the Kitchen had not been completed during October 2019.

Failure to conduct monthly inspections of the wet chemical extinguishing system increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined numerous smoke detectors throughout the facility were installed within 36 in. of an air supply diffuser or return air opening.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25 4.1.4.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and interview with staff determined the control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

Fire extinguishers having a gross weight not exceeding 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). NFPA 10 6.1.3.8.1, 6.1.3.8.2, 6.1.3.8.3

The facility failed to install fire extinguishers in accordance with NFPA 10.

Observation determined nine (9) portable fire extinguishers throughout the facility were installed with the top of the extinguisher more than 5 ft. above the floor.

Failure to install fire extinguishers in accordance with NFPA 10 increases the risk of injury or death due to fire.

The deficiency affected nine (9) of numerous fire extinguishers in the facility.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)(1), 210.8(B)(2), 210.8(B)(5)

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Observation determined:

1) Numerous electrical receptacles in Bathrooms throughout the facility were not ground-fault circuit-interrupter protected.

2) Numerous electrical receptacles within 6 ft. of a sink were not ground-fault circuit-interrupter protected.

3) Numerous electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected numerous electrical receptacles in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined no fire drills were conducted on the Night Shift during the first and second quarters of 2019.

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

The deficiency affected two (2) of twelve (12) drills in the past year.