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Based on an observation the the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3 and 19.3.2.1.5 (7).

This deficiency affects 1 of 6 smoke compartments.

Findings include:

During an observation on 6/12/24 at 12:10 p.m., the PT storage room was inspected. The room was being used as storage, was 81 square feet, and the door leading to the room lacked a self-closure.

Based on interview and record review the facility failed to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2. This deficiency affected all smoke compartments in the facility.

Findings include:

Review of sprinkler inspection records on 6/12/24 showed there was not a sprinkler inspection completed for the first quarter of 2024 (January - March).

During an interview on 6/12/24 at 11:20 a.m., staff member B stated there was not a sprinkler inspection completed for the first quarter of 2024. Staff member B stated the inspector was sick and pushed back the inspection into the second quarter of 2024.

Based on an observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

This deficiency affected 1 of 6 smoke compartments in the facility.

Findings include:

During an observation at 6/12/24 at 12:16 p.m., the boiler room was inspected. A portable fire extinguisher was observed, blocked by storage of various items.