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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.

Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Automatic wet chemical fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and NFPA 17A, Standard for Wet Chemical Extinguishing Systems. 19.3.2.5.1, 9.2.3, NFPA 96 10.2.6(4).

1) 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 55 inches above the floor.

2) The facility failed to inspect, test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems and NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

a) 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. NFPA 17A 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed during the past seven months..

b) 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. NFPA 96 11.2.1.

Record review determined the fire-extinguishing system serving the Kitchen exhaust hood was last inspected and serviced on 03/21/2022 by an outside company, exceeding the required 6 months testing requirement.

Failure to install, inspect, test and maintain the wet chemical extinguishing system in accordance with NFPA 96 and NFPA 17A 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.

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 gauges of the automatic sprinkler system had not been inspected during all months in the past year.

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 seven (7) 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 seven (7) 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, 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:

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

2) One (1) electrical receptacle in the Beauty Shop within 6 ft. of a sink was 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.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5.2.1, 9.2.1, NFPA 90A 5.4.8.1, NFPA 80, 19.4

The facility failed to test and inspect fire dampers in accordance with NFPA 80.

Review of records and staff interview determined the tests and inspections of fire dampers were not performed as required. On 11/30/2022, no records of tests and inspections of fire dampers were available.

Failure to test and inspect fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected all fire dampers in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined fire drills did not include the simulation of an emergency phone call to the fire department.

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

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

The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110.

Record review and interview with staff determined the monthly test of the emergency generator conducted on 06/17/2022 exercised the emergency generator under load for only 20 minutes not the required 30 minutes.

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 twelve (12) monthly tests of the emergency generator which provides all emergency power to the facility.