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The facility failed to ensure vertical openings were enclosed with construction having a fire-resistance rating of at least 1-hour.

A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position. 19.3.1.7

Observation determined the stairway doors in the following locations failed to self-close and latch into the door frame.

1- The stairway door to the middle stairway on the first floor.
2- The stairway door to the east stairway on the ground floor.
3- The stairway door to the east stairway on the first floor.

Failure to protect vertical openings increases the risk of injury or death due to fire.

This deficiency affected three (3) of nine (9) corridor doors into exit stairways in the facility.

Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. 19.3.2.5.1, 9.2.3, NFPA 96 11.2.1.

The facility failed to test and service the fire-extinguishing system serving the Kitchen exhaust hood in accordance with NFPA 96.

Record review determined the fire-extinguishing system serving the Kitchen exhaust hood was last inspected and serviced on 03/11/2024 by an outside company. No other inspection was completed in the past year.

Failure to inspect and service the fire-extinguishing system for the Kitchen exhaust hood at required intervals increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) required inspections of the Kitchen exhaust hood fire-extinguishing system in the past year.

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 03/11/2024. 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.

Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1)

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)

NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters.

Observation determined one (1) sprinkler in the Garage installed within 7 ft. of a horizontal discharge unit heater was not high-temperature-rated.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury or death due to fire.

The deficiency affected one (1) of numerous locations protected by the automatic sprinkler system, which serves the entire facility.

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

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, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages 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)

Observation determined numerous electrical outlets in the Garage were not ground fault 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 Garage.