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1. Based on document review and staff interview, the facility failed to provide a letter of reliability in accordance with the 2012 NFPA 101, Life Safety Code, the 2012 NFPA 99, Healthcare Facilities Code, and NFPA 110, Standard for emergency and standby power systems. The failure to prove reliable access to natural gas as required could result in injury or death due in an emergency. The deficiency affected one (1) of one (1) generator for the facility. The findings were:

Document review on 06/15/2023 at 11:48 AM revealed that no letter from the natural gas provider was available to provide proof of low probability of interruption and demonstrated reliability.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Sections 19.5.1, 9.1, 9.1.2, and 9.1.3.1
2012 NFPA 99, Sections 6.4.1, 6.4.1.1, 6.4.1.1.1.2 and 6.4.1.1.4
2010 NFPA 110, Section 5.1, 5.1.4

2. Based on document review and staff interview, the facility failed to provide a remote emergency stop for the emergency generator in accordance with the 2012 NFPA 101, Life Safety Code, the 2012 NFPA 99, Healthcare Facilities Code, and NFPA 110, Standard for Emergency and Standby Power Systems. The failure to provide a remote method to shut down the generator as required could result in injury or death in an emergency. The deficiency affected one (1) of one (1) generator for the facility. The findings were:

Observation on 06/15/2023 at 2:23 PM revealed that no manual emergency stop station could be located remote from the generator.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Sections 19.5.1, 9.1, 9.1.2, and 9.1.3.1
2012 NFPA 99, Sections 6.4.1.1.16.2, and Table 6.4.1.1.16.2(v)
2010 NFPA 110, Section 5.6.5.6

3. Based on document review and staff interview the facility failed to exercise the generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Failure to exercise the generator could result in the generator not functioning in an emergency. The deficiency affected one of multiple generator testing requirements. The findings were:

Document review on 06/15/2023 at 2:45 PM revealed that 4 hour generator load testing had not been performed in the past 36 months.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 110, Sections: 8.3.7.1
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Based on observation and staff interview, the facility failed to maintain stairwells clear of storage materials in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain clear stairwells as required could delay egress, resulting in injury or death during an emergency. The deficiency affected one (1) of six (6) stairwells in the facility. The findings were:

Observation on 06/15/2023 at 12:07 PM in the stairwell to the basement revealed combustibles stored on the 1st floor landing.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Section 19.2.2.3; 7.2.2.5.1.1; 7.1.3.2.3
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Based on observation and staff interview, the facility failed to have the kitchen extinguishing system inspected in accordance with the 2012 NFPA 101, Life Safety Code. and the 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to have the kitchen extinguishing system inspected as required could result in injury or death during an emergency. The deficiency could affect all staff working within the kitchen area, as well as staff, patients, and visitors throughout the building. The findings were:

Document review on 06/15/2023 at 12:35 PM revealed that only one of the required semi-annual inspections of the kitchen hood had been completed in the past 12 months.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 19.3.2.5.1, 9.2.3
2011 NFPA 96, Sections: 11.5
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Based on observation and staff interview, the facility failed to maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm Code. Failure to maintain fire detection systems as required could result in injury or death during an emergency. The deficiency affected one (1) of numerous requirements for the fire alarm system. The findings were:

Observation on 06/15/2023 at 12:25 PM at the fire annunciator panel revealed that the Underwriter's Laboratory (UL) certification for the fire alarm was expired.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA Sections 19.3.4.1; 9.6.1.3
2010 NFPA 72 Section 26.3.4.3
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1. Based on observation and staff interview, the facility failed to maintain sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. The failure to maintain sprinkler systems as required could result in injury or death during an emergency. The deficiency affected one (1) of numerous storage areas throughout the facility. The findings were:

Observation on 06/15/2023 at 12:29 PM in the basement electrical room revealed storage stacked within the 18" height clearance to the sprinkler head, which results in an obstruction to the dispersion pattern of the affected sprinkler.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.3.5.1; 9.7.5
2011 NFPA 25, Section 5.2.1.2

2. Based on observation and staff interview, the facility failed to have sprinkler systems installed in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. The failure to install sprinkler systems as required could result in a delayed response, or malfunction, of the sprinkler system during an emergency. The deficiency could impact all staff working within the kitchen, as well as staff, patients, and visitors throughout the facility. The findings were:

Observation on 06/15/2023 at 12:37 PM in the walk in kitchen freezer and refrigerator revealed the color of the sprinkler bulb fluid to be red, which indicated an improper sprinkler type for ambient conditions.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Section 8.3.2.5, Table 6.2.5.1
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Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was observed in one (1) of numerous above ceiling areas. The findings were:

Observation on 06/15/2023 at 1:50 PM in the above ceiling corridor area, by room 24, revealed that a small quantity of roof insulation had become unattached from the underside of the roof, and fallen to the upper side of the ceiling. In one instance, this insulation had fallen on top of the sprinkler piping.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections 19.3.5.1, 9.7.5
2011 NFPA 25, Section: 5.2.2.2
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Based on observation and staff interview, the facility failed to provide access to fire extinguishers in accordance with the 2010 NFPA 10, Standard for Portable Fire Extinguishers, and the 2012 NFPA 101, Life Safety Code. Failure to provide access to a fire extinguisher as required may lead to injury or death during an emergency. The deficiencies affected one (1) of numerous fire extinguishers in the facility. The findings were:

Observation on 06/15/2023 at 1:20 PM in the corridor by soiled utility revealed that the fire extinguisher had been obstructed by a cart.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency..

REF: 2012 NFPA 101, Sections 19.3.5.312, 9.7.4.1
2010 NFPA 10, Sections 6.1.3.1; 6.1.3.3.1

1. Based on document review and staff interview, the facility failed to provide a letter of reliability in accordance with the 2012 NFPA 101, Life Safety Code, the 2012 NFPA 99, Healthcare Facilities Code, and NFPA 110, Standard for emergency and standby power systems. The failure to prove reliable access to natural gas as required could result in injury or death due in an emergency. The deficiency affected one (1) of one (1) generator for the facility. The findings were:

Document review on 06/15/2023 at 11:48 AM revealed that no letter from the natural gas provider was available to provide proof of low probability of interruption and demonstrated reliability.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Sections 19.5.1, 9.1, 9.1.2, and 9.1.3.1
2012 NFPA 99, Sections 6.4.1, 6.4.1.1, 6.4.1.1.1.2 and 6.4.1.1.4
2010 NFPA 110, Section 5.1, 5.1.4

2. Based on document review and staff interview, the facility failed to provide a remote emergency stop for the emergency generator in accordance with the 2012 NFPA 101, Life Safety Code, the 2012 NFPA 99, Healthcare Facilities Code, and NFPA 110, Standard for Emergency and Standby Power Systems. The failure to provide a remote method to shut down the generator as required could result in injury or death in an emergency. The deficiency affected one (1) of one (1) generator for the facility. The findings were:

Observation on 06/15/2023 at 2:23 PM revealed that no manual emergency stop station could be located remote from the generator.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Sections 19.5.1, 9.1, 9.1.2, and 9.1.3.1
2012 NFPA 99, Sections 6.4.1.1.16.2, and Table 6.4.1.1.16.2(v)
2010 NFPA 110, Section 5.6.5.6
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Based on document review and staff interview the facility failed to exercise the generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Failure to exercise the generator could result in the generator not functioning in an emergency. The deficiency affected one of multiple generator testing requirements. The findings were:

Document review on 06/15/2023 at 2:45 PM revealed that 4 hour generator load testing had not been performed in the past 36 months.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 110, Sections: 8.3.7.1
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Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 70, National Electrical Code. The failure to maintain electrical systems as required could result in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 06/15/2023 at 1:27 PM in storage C revealed multiple obstructions in front of the electrical panel. A working space of three (3) feet in front of the panels is to be maintained.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.5.1.1; 9.1.2
2011 NFPA 70, Section: 210.8(B)(5)
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Based on observation and staff interview, the facility failed to maintain oxygen storage in excess of 3,000 cubic feet in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to maintain oxygen storage as required could result in injury or death. The deficiency affected one (1) of one (1) oxygen storage locations at the facility. The findings were:

Observation on 06/15/2023 at 12:22 PM of the oxygen storage room revealed that the door was not provided with language in accordance with NFPA 99.

Interview with the facilities director at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 99, Sections 11.3.4.1, 11.3.4.2