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Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96,

Commercial cooking items under suppression system do not permit equipment in place to return after cleaning
Kitchen Suppression system bottle overdue hydro report shows it was due in 2022


NFPA 96
11.2.1* 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.

11.2.2* All actuation and control components, including remote manual pull stations, mechanical and electrical devices, detectors, and actuators, shall be tested for proper operation during the inspection in accordance with the manufacturer ' s procedures.

NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations.

NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location.


This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the facility. Deficient items were discussed with the maintenance director and administrator at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101

No report available for 3 year dry valve trip test for dry sprinkler system


NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the facility. Deficient items were discussed with the maintenance director and administrator at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1.

This was evidenced by the following:

Penetrations/Non Listed fire walls repairs found by room dining room, Emergency Department, Electrical room, staff workroom 1323 (areas identified during survey)

NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the facility. Deficient items were discussed with the maintenance director and administrator at the exit conference..

Based on observation during the survey, it was determined that the facility failed to maintain proper gas practices in accordance with Life Safety Section 9.1 and NFPA 54, 11.1.2.
This was evidenced by the following:

Gas orifice on dryer rated for 0-2000 feet in elevation in laundry room.

NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code.

NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:
(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance

(2) As permitted by the authority having jurisdiction.
(3) In accordance with the manufacturer ' s installation instructions.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the facility. Deficient items were discussed with the maintenance director and administrator at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:

No polarity/retention testing for patient bed area report available (only GFI report available)

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the facility. Deficient items were discussed with the maintenance director and administrator at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following:

External a remote manual stop station needed for generator

NFPA 110
5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the facility. Deficient items were discussed with the maintenance director and administrator at the exit conference.