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Based on observation, staff interview and record review, the facility failed to ensure that the kitchen range hood, grease removal devices, fans, ducts, and other appurtenances at intervals prior to surfaces becoming heavily contaminated with grease or oily sludge in compliance with NFPA 96. The deficient practice provides fuel for cooking equipment to ignite, affecting approximately 39 residents in one of eight smoke zones. The facility has a capacity of 53 and census of 39 at the time of the survey.

Findings include:

During the inspection on 1/15/19 at 11 am the following is identified:

1. The lights above the kitchen grill contained exposed wiring that were contaminated with grease.

Staff A was present during the survey and acknowledged the finding.

Review of the following NFPA Standard revealed: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.3

Review of the following NFPA Standard revealed: The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 2011 NFPA 96, 11.4

Review of the following NFPA Standard revealed: Lighting fixtures (luminaries) in permanently installed hoods are permitted per Section 410.10 (C) of the NEC provided the following four conditions are met
1. The luminaire is identified for use in commercial cooking hoods and is installed in such a manner that the temperature limits of the material used in its construction are not exceeded.
2. Luminaire construction shall be such that all grease, exhaust vapors, oil or cooking vapors are excluded from the lamp and wiring compartments. If diffusers are used, they must be resistant to thermal shock. 3. Exposed portions of the luminaire must be corrosion resistant and designed to facilitate cleaning. 4. Wiring methods and materials shall not be exposed within the cooking hood. Section 410.10, 2008 NFPA 70

Review of the following NFPA Standard revealed: Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction.
2011 NFPA 96, 11.6.1

Review of the following NFPA Standard revealed: When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises. After cleaning or inspection is completed, the exhaust cleaning company and the person performing the work at the location shall provide the owner of the system with a written report that also specifies areas that were inaccessible or not cleaned. Where required, certificates of inspection and cleaning and reports of areas not cleaned shall be submitted to the authority having jurisdiction.
2011 NFPA 96, 11.6.13 through 11.6.15

Based on observation, staff interview, and record review the facility failed to provide a sprinkler system installed in accordance with NFPA 13. Failing to meet the requirement to provide an automatic fire sprinkler system in accordance with the requirements of NFPA 13 may not prevent fire growth, affecting 15 patients in one of eight smoke zones. The facility has a capacity of 53 and census of 39 at the time of the survey.

Findings include:

During the inspection on 1/15/19 at 11:30 am the following is identified:

Patient room storage closets in the wing housing resident room 213 contain active sprinkler heads above the drop ceiling, thus not installed to provide complete coverage throughout the space.

Staff A was present during the survey and acknowledged the finding.

Review of the following NFPA Standard revealed: Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101, 19.3.5.1

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:

(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2012 NFPA 101, 9.7.1.1

Review of the following NFPA Standard revealed: When backflow prevention devices are to be retroactively installed on existing systems, a thorough hydraulic analysis, including revised hydraulic calculations, new fire flow data, and all necessary system modifications to accommodate the additional friction loss, shall be completed as a part of the installation. 2010 NFPA 13, 8.17.4.6.2

Review of the following NFPA Standard revealed: The requirements for spacing, location, and position of sprinklers shall be based on the following principles:

(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure. 2010 NFPA 13, 8.1.1

Review of the following NFPA Standard revealed: Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. 2010 NFPA 13, 8.5.5.3

Review of the following NFPA Standard revealed: Automatic sprinklers shall not be obstructed by auxiliary devices, piping, insulation, and so forth, from detecting fire or from proper distribution of water. 2010 NFPA 13, 7.7.1.4

Review of the following NFPA Standard revealed: Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sidewall sprinklers shall be installed no closer than 4 ft (1.2 m) from light fixtures or similar obstructions. The distance between light fixtures or similar obstructions located more than 4 ft (1.2 m) from the sprinkler shall be in conformity with Table 8.7.5.1.3 and Figure 8.7.5.1.3.
2010 NFPA 13, 8.7.5.1.1 through 8.7.5.1.3

Based upon observation and staff interview the facility is not ensuring that doors to a corridor close and latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine and smoke products and to properly defend occupants in place, affecting approximately 13 residents in one of eight smoke zones. The facility has a capacity of 53 with a census of 39 patients at the time of the survey.

Findings include:

During the inspection conducted on 1/15/19 the following is identified:

1) At 11:15 am the door to patient room 209 did not latch tightly in the frame when tested.

2) At 12 pm the door to team conference room in 201 hallway did not latch tightly in the frame when tested.

Staff A was present during the survey and acknowledged the findings.

NFPA Standard: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting 15 residents in one of eight smoke zones. The facility has a capacity of 53 with a census of 39 at the time of the survey.

Findings include:

During the survey on 1/15/19 the following was identified:
1) At 11:45 the light fixture in the storage room located near oxygen storage room, by the 2nd floor elevator is missing its cover.
2) At 12:15 pm an open junction box is present in elevator #2 shaft (viewable from 2nd floor)
Staff A was present during the survey and acknowledged the findings.
Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NAPA 101, 9.1.2