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Based on observations and staff interview, the facility failed to maintain the kitchen hood system in the facility in accordance with LSC Sections 19.3.2.5.1., 9.2.3, NFPA 96 (2014). Failure to maintain the cooking hood equipment endangers patients, staff, and other building occupants.

The findings include:


During the facility tour with the Maintenance Director on 10/24/19 from 2:20 PM to 5:30 PM, in the kitchen, observed fire suppression system nozzles misaligned over the cooking equipment.

During an interview with the Maintenance Director on 10/24/19 at 3:45 PM, he confirmed the observations and the findings.

NFPA 101 (2015) 19.3.2.5.1., 9.2.3.
NFPA 96 (2014)

An exit conference was conducted on 10/24/19 at 5:30 PM, these findings were verified by the Maintenance Director at the times of observation and with the Administrator.

Based on documentation review and staff interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of staff and other building occupants, which could result in injury or loss.

The findings include:

Based on documentation review and staff interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of staff and other building occupants, which could result in injury or loss.

The findings include:
During document review with Maintenance Director on 10/24/19 at 9:10 AM, the facility failed to provide documentation for the fire alarm system smoke and duct detectors biennial sensitivity inspection.

During the documentation review on 10/24/19 at 10:16 AM,with the Maintenance Director it was found that not all devices had been tested, inspected, and maintained to ensure the integrity of the fire alarm system. Duct detector devices were missed, and not marked on inspection documents as being verified utilizing sampling tubes for the correct pressure differential (within the manufacturer's published ranges) between the inlet and exhaust tubes.

During an interview with the Maintenance Director on 10/24/19 at 10:20 AM,with the Maintenance Director stated he does acknowledged that there were no records to show that the duct detector devices had been verified for differential pressure. The Maintence Director concurred with both the observations and record review.

NFPA 101(2015 Edition) 19.3.4.4, 9.6.1.5
NFPA 72 (2013 Edition) 14.4.5.3

An exit conference was conducted on 10/24/19 at 5:30 PM, These findings were verified by Maintenance Director at the times of observation and with the Administrator.

Based on observation and staff interview, the facility has failed to install and maintain their fire sprinkler system in accordance with NFPA 101 (2012). Un-sprinkled areas can allow a fire to grow beyond the incipient stage, endangering resident, visitors and staff.

The findings include:

During the facility tour with the Maintenance Director on 10/24/19 from 2:20 PM to 5:30 PM, it was found that the building was partially sprinkled with thirteen sprinkler heads installed on domestic water supply, there is an allowance to install up to 6 sprinkler heads for the protection of a hazardous area without requiring a licensed sprinkler contractor and design as required per NFPA 101 (2012) 9.7.1.2. Facility fail to produce documentation for the thirteen sprinkler heads design and water supply.

During an interview on 10/24/19 at 5:30 PM,with the Maintenance Director concurred with the observations and confirmed the findings.

NFPA 101 (2015) 19.3.5.1., 9.7.1.2.

These findings were verified by Maintenance Director at the times of observation and the Administrator at the exit conference on 10/24/19 at 5:45 PM.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system/components in the facility in accordance with LSC Sections 19.3.5., 9.7.5. The facility failed to maintain and inspect sprinkler system which could fail to perform properly endangering the patients, staff, and other building occupants.

The findings include:

During the facility tour with the Maintenance Director on 10/24/19 at 2:20 PM to 5:30 PM, on exterior/backflow preventer/ fire department connection, observed fire department connection (FDC) location signage was not installed.

During an interview with the Maintenance Director on 10/24/19 at 2:42 PM, he concurred with the observations and confirmed the findings.

NFPA 101 (2015) 19.3.5., 9.7.5.
NFPA 25 (2014) 13.7.1. (1), 13.7.4.

An exit conference was conducted on 10/24/19 at 5:30 PM, These findings were verified by Maintenance Director at the times of observation and with the Administrator.

Based on observation and interview, the facility failed to install portable fire extinguishers in a manner that would allow immediate recognition of the fire extinguishers. This in the event of a fire could delay the response in locating and utilizing the portable fire extinguisher.

The findings include:

During the facility tour with the Maintenance Director on 10/24/19 at 2:20 PM to 5:30 PM, the fire extinguisher cabinets in the corridors were all of the flush mounted recessed type. There was no visual indicator to identify the location of the extinguishers. Fire extinguishers shall not be obstructed or obscured from view and means shall be provided to indicate the extinguisher location. The location of fire extinguishers shall be marked conspicuously. The following areas:
1) Kitchen/next to office
2) Operating rooms area

During an interview with the Maintenance Director on 10/24/19 at 4:50 PM, with the Maintenance Director he concurred with the observations and confirmed the findings.

NFPA 101 (2015) 19.3.5.12., 9.9.
NFPA 10 (2013) 6.1.3.3; 6.1.3.10

An exit conference was held on 10/24/19 at 5:30 PM, these findings were verified by both the maintence Director and Administrator.

Based on observation and staff interview, the facility failed to maintain and inspect fire and smoke barriers in the facility in accordance with LSC Sections. Failure to maintain smoke barriers endanger patients, staff, and other building occupants from toxic gases and smoke.

The findings include:


During the facility tour with the Maintenance Director on 10/24/19 from 2:20 PM to 5:30 PM, it was found that the smoke/fire walls were not properly protected with the required firestopping system in the following areas:

1) Exterior/mechanical room, observed penetration in ceiling
2) Vacuum pump room, observed penetration in ceiling
3) Fire walls/North/South, observed penetrations in wall above the ceiling

NFPA 101 (2015) 19.3.7.3., 8.3.

During an interview with the Maintenance Director on 10/24/19 at 4:50 PM, with the Maintenance Director he concurred with the observations and confirmed the findings.

An exit conference was held on 10/24/19 at 5:30 PM, these findings were verified by both the maintence Director and Administrator.

Based on records review and staff interview, the facility failed to maintain the medical gas system in according with NFPA 99. Failure to maintain the medical gas system endangering patients during procedures.

The findings include:

During the documentation review on 10/24/19 at 12:30 PM,with the Administrator the facility failed to produce documentation for medical gas system and vacuum pump inspection.

During an interview with the Maintenance Director on 10/24/19 at 12:35 PM,with the Maintenance Director concurred with the observations and confirmed the findings.

NFPA 99 (2015) 5.1.14.2.1. thru 5.1.14.2.2.4.

An exit conference was held on 10/24/19 at 5:45 PM, These findings were verified by Administrator at the times of observation.






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Based on documentation review and staff interview, the facility failed to maintain electrical system in the facility. Overloading of electrical circuit leads to overheating of wires, short circuits, hot spots, and fire. Endangering patients, staff, and other building occupants.

The findings include:

During the documentation review with the Maintenance Director on 10/24/19 at 12:08 PM, facility fail to produce documentation for electrical receptacles inspection, receptacles in patient care areas and GFCI shall be tested, inspected, and maintained to ensure the integrity of the electrical system.

During an interview with the Maintenance Director on 10/24/19 at 12:11 PM,with the Maintenance Director he acknowledged the electrical receptacles testing and inspection was not conducted in all required areas.

NFPA 101 (2012) 19.5.1., 9.1.
NFPA 99 (2012) 6.3.2.2.4.2.
NFPA 70 (2011)

These findings were verified by Maintenance Director at the times of observation and the Administrator at the exit conference on 10/24/19 at 5:45 PM.

Based on observation and staff interview, the facility failed to maintain electrical receptacles in the facility. Unidentified electrical receptacles endangers patients, staff, and other building occupants.

The findings include:

During the facility tour with the Maintenance Director on 10/24/19 at 2:20 PM to 5:30 PM, in Pharmacy, it was found that electrical receptacle supplied from the life safety and critical branches wasn't a distinctive color.

During an interview on 10/24/19 at 4:20 PM, with the Maintenance Director he acknowledged the electrical receptacles on the life safety branch wasn't a distinct color.

NFPA 101 (2015) 19.5.1., 9.1.
NFPA 99 (2015) 6.4.2.2.6., 6.5.2.2.4.2., 6.6.2.2.3.2.

An exit conference was held on 10/24/19 at 5:45 PM, with both the Administrator and Maintennce Director who confirmed the findings of the survey.

Based on record review and staff interview with the maintenance director, the facility failed to provide evidence of generator maintenance and testing in accordance with NFPA 110 (2010). Failure to maintain the prime mover will result in a loss of power to the facility thus endangering the residents and occupants of the facility.

The finding include:
During the documentation review on 10/24/19 at 10:16 AM, with the Maintenance Director the facility failed to produce evidence of monthly under load testing for emergency generator.

An interview was conducted with the maintenance director concurrent with the observations and confirmed the findings.

NFPA 99 (2012 Edition) 6.4.1.1.13
NFPA 110 (2010 Edition) 8.1, 8.3, 8.3.7.1, 8.4, 8.4.2


During the documentation review with the Maintenance Director on 10/24/19 at 11:46 AM, the facility failed to produce documentation for emergency generator diesel fuel quality testing. There was no record of a fuel sample being drawn by the facility or their vendor.

During an interview on 10/24/19 at 11:46 AM, with the Maintenance Director who stated he was unable to produce record of the fuel sample being tested.

NFPA 110 (2010 edition) 8.3.8

An exit conference was held on 10/24/19 at 5:45 PM, with both Administrator and Maintenance Director who verified the observations and the findings of the survey.

Based on observation and staff interview, the facility failed to maintain power strips and extension cords in the facility in accordance with LSC Sections 19.5.1., 9.1.2. Improper power strip and extension cord use endangers patients, staff, and other building occupants.

The findings include:

During the facility tour with the Maintenance Director on 10/24/19 at 2:20 PM to 5:30 PM, observed power strips being used incorrectly and as a permanent receptacle in following areas:

1) Pharmacy- refrigerator plugged into power strip and power strip plugged into power strip
2) Phlebotomy - refrigerator plugged into power strip, used as permanent receptacle
3) Lab. office, observed extension cord in use

During an interview with the Maintenance Director on 10/24/19 at 4:40 PM, he concurrent with the observations and confirmed the findings.

NFPA 101 (2012) 19.5.1, 9.1.2.
NFPA 99 (2012) 10.2.4., 10.2.3.6.
NFPA 70 (2011) 400-8., 590-3 (D)

These findings were verified by Maintenance Director at the times of observation and the Administrator at the exit conference on 10/24/19 at 5:30 PM.