Belmont Village West University Tenant, LLC

The facility failed to ensure an emergency generator was in compliance with licensing standards for assisted living facilities.

The facility failed to ensure the fire alarm panel had separate zones for each floor and/or smoke compartment, and had both alarm and trouble signals for each zone.

The facility failed to provide and/or maintain a commercial range hood and exhaust system in compliance with NFPA 96.

The facility failed to provide an elevator.

The facility failed to conduct and document a risk assessment for potential emergencies or disasters.

The facility failed to comply with Chapter 19 of NFPA 101.

The facility failed to ensure the required sprinkler system was inspected, tested, and maintained in compliance with NFPA 25.

The facility failed to provide a monitoring station (or failed to provide details about the monitoring station) for the segregated unit.

The facility failed to ensure all monthly and yearly extinguisher inspections were performed and/or documented; and/or that unserviceable extinguishers were replaced.

The facility failed to ensure that locking devices on exit doors complied with Special Locking Arrangements in the Life Safety Code.

The facility failed to provide the required sprinkler system to meet NFPA 13.

The facility failed to ensure locked gates were in compliance with licensing standards for assisted living facilities.

The facility failed to ensure fire drills were conducted and documented to be in compliance with licensing standards for assisted living facilities.

The facility failed to ensure the fire alarm and smoke detection system was in compliance with licensing standards for assisted living facilities.

The facility failed to ensure an annual inspection was conducted by the local fire marshal.