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The facility failed to ensure exits were arranged to provide a continuous path of escape.

Observation determined the access to the east stair enclosure on the fourth and fifth floor was through intervening spaces. The fourth floor must exit through the Surgical Suite and the fifth floor must exit through the PT/OT Suite to reach the east stair enclosure.

Failure to ensure access to exits does not travel through intervening spaces increases the risk of injury or death due to fire.

This deficiency affected exits on two (2) of five (5) floors in the facility.

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

Observation determined the fifth floor east stair enclosure wall between the PT/OT suite and the stairway terminated at the ceiling.

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

This deficiency affected one (1) of five (5) stair enclosures in the facility.

The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1.

Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 58 inches above the floor.

Failure to inspect, maintain, and install the wet chemical extinguishing system in accordance with NFPA 96 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.

The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit. NFPA 72 10.5.5.2.1

The facility failed to ensure the fire alarm system was in compliance with NFPA 72.

Observation determined the location of the circuit disconnecting means was not permanently identified at the fire alarm control unit.

Failure to permanently identify the location of the branch circuit disconnecting means at the fire alarm control increases the risk of injury or death due to fire.

This deficiency affected the entire facility. The fire alarm system serves the entire building.

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)

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

Observation determined 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.