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Based on record review and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect 12 out of 12 occupants in the event of a fire emergency.

Findings Include:
On August 9, 2022, between 12:00 PM - 2:30 PM, record review revealed the facility failed to provide documentation at the time of survey of a kitchen hood cleaning and inspection at a minimum of 6 (six) month intervals as required per NFPA 96, section 11.4 & 11.6.

The facility Environmental Services Director confirmed these findings during interview at the time of record review.

Based on record review and interview, the facility failed to ensure when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (AHJ) has been notified, and all unprotected areas of the building have been evacuated or an approved Fire Watch is provided until the system is restored as required by 9.6.1.6. This deficient practice could affect 12 out of 12 occupants in the event of an impairment of the fire alarm system.

Findings Include:
On August 9, 2022, between 12:00 PM - 2:30 PM, record review revealed the document provided to surveyor at the time of survey titled, "1ES Fire Alarm System Failure Policy" for the fire alarm out of service policy stated, "in the event of the fire alarm system being out of service for more than 10 hours in a 24-hour period, the Bureau of Fire Services (BFS) will be notified, and an approved fire watch shall be implemented until the fire alarm system has been returned to service". The policy does not provide information to contact all authorities having jurisdiction including the Bureau of Survey and Certification (BSC), contact numbers for the authorities having jurisdictions (BFS & BSC, 1-800-882-6006), and per NFPA 101, 9.6.1.6 requires fire alarm system is out of service for more than 4 hours, not 10 hours.

The facility Environmental Services Director confirmed these findings during interview at the time of record review.

Based on record review and interview, the facility failed to ensure when the sprinkler system is out of service for more than 10 hours in a 24-hour period, the affected areas are evacuated or an approved Fire Watch is provided until the sprinkler system is returned to service as required by 19.3.5.1 and 9.7.5 of the LSC and 15.5.2 of NFPA 25. This deficient practice could affect 12 out of 12 occupants in the event of an impairment of the automatic sprinkler system.

Findings Include:
On August 9, 2022, between 12:00 PM - 2:30 PM, record review revealed the document provided to surveyor at the time of survey titled, "2ES Fire Alarm System Failure Policy" for the automatic sprinkler system out of service does not contain all the required criteria. All names of the authorities having jurisdictions (Bureau of Fire Services (BFS) & Bureau of Survey and Certification (BSC)), the appropriate contact numbers for the authorities having jurisdictions (BSC 1-800-882-6006), a method of staff notification of the fire watch being in effect, names and contact numbers of all involved parties including insurance companies, fire department, property owner as required per NFPA 25, 15.5.2(4)(5) & 15.6. This could potentially mislead or misguide staff in the event of a sprinkler system impairment.

The facility Environmental Services Director confirmed these findings during interview at the time of record review.

Based on observation and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect 12 out of 12 occupants in the event of a fire emergency.

Findings Include:
On August 10, 2022, at approximately 8:30 AM, observation revealed in the gas manifold room (1157) there is no defined segregation between full and empty oxygen cylinders. The "E" size oxygen cylinders were observed grouped together with a lightweight chain holding them together, but the cylinders could easily be knocked over. As required per NFPA 99, 5.1.3.3.2(9) - storage shall use racks, shelves constructed of noncombustible materials or limited-combustible materials, & NFPA 99, 11.6.5.1 thru 11.6.5.3.

The facility Environmental Services Director confirmed these findings during interview at the time of observation.