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Based on record review and interview, the facility did not inspect the kitchen range hood equipment in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.5 & 9.2.3; and NFPA 96 (2011 edition) Sections 10.2.2, NFPA 10 (2010 edition) Sections 5.5.5 & 5.5.5.3. These deficient practices could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 08/01/2022 at 10:48 am, review of inspection records for the kitchen-hood exhaust and fire suppression system revealed that one (1) semi-annual inspection was conducted over the past 12 months, by Certa Cite on 01/27/2022. The prior semi-annual inspection had been conducted by Certa Cite on 03/08/2021.

2. On 08/01/2022 at 2:20 pm, observation in the kitchen at the Class K portable fire extinguisher revealed that there was no placard containing instructions on the use the portable fire extinguisher after the fixed fire protection system was activated.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff O, Staff P and Staff Q.

Based on record review and interview, the facility did not provide records where required fire alarm system is out of service for more than 4 hours in a 24-hour period as required in NFPA 101 - 2012 edition, Section 9.6.1.6. This deficient practice had the potential to affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 08/01/2022 at 11:54 am, record review revealed that the facility did not have a separate plan to address fire alarm outages. The plan is to provide guidance for outages of the fire alarm system of more than 4 hours in a 24-hour period. The facility had a plan titled "Fire Watch" dated 07/2021.

2. On 08/01/2022 at 11:55 am, record review revealed that the facility did not have e-mail contact information for the regional fire authority, vendor contact list nor language indicating that fire alarm outage rounds are to be continuous.

These findings were confirmed at the time of discovery by a concurrent interview with Staff O and Staff P.

Based on document review and staff interview, the facility did not provide a separate plan to respond to outages of the sprinkler system in accordance with NFPA 101 (2012 ed) 9.7.6. This deficiency had the potential to affect all residents as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1.On 08/01/2022 at 11:56 am, review of facility documents revealed that the facility did not have a separate plan to address sprinkler outages. The plan is to provide guidance for outages of the sprinkler system of more than 10 hours in a 24-hour period. The facility had a plan titled "Fire Watch" dated 07/2021.

2.On 08/01/2022 at 11:56 am, review of facility documents revealed that the facility's "Fire Watch" plan did not have e-mail contact information for notification of the regional fire authority, vendor contact list nor language indicating that fire alarm outage rounds are to be continuous.

This condition was confirmed at the time of discovery by a concurrent interview with Staff O and Staff P.

Based on observation, record review, and interview the facility did not ensure boilers were maintained in accordance with NFPA 101 (2012 edition) Sections 1.4.2. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/01/2022 at 12:07 pm, record review of facility's electronic files revealed that the facility's boiler inspection record indicated that the permit to operate had expired on 12/10/2021. This included three hot water boilers and two steam boilers numbered 1251163 to 1251167.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff O and Staff P.

Based on record review and interview, the facility failed to provide a permit to operate the elevator as required by NFPA 101 (2012 edition), Sections 19.5.3 and 9.4.2. This deficient practice could affect all patients an undetermined number of staff and visitors.

Findings include:

On 08/01/2022 at 12:07 pm, record review of facility's electronic files revealed that the facility's elevator inspection record indicated that the permit to operate had expired on 06/04/2021.

This condition was confirmed at the time of discovery by Staff O and Staff P.

Based on observation and interview, the facility failed to maintain a clear working space in front of one electrical panel in accordance with NFPA 101 (2012 edition) Section 9.1.2; NFPA 70 (2011 edition) Sections 110.26 & 110.34 (A). The deficient practice could affect all patients, as well as an undetermined number of staff and visitors

Findings include:

1. On 08/01/2022 at 1:15 pm, observation in the Operating Room #4 revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. A blood pressure monitor was stored six inches in front of the electrical panel and was plugged into the wall outlet on the abutting wall next to the panel.
2. On 08/01/2022 at 1:38 pm, observation in the Operating Room #9 revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. A surgical suction machine was stored 1 foot in front of the electric panel.
3. On 08/01/2022 at 1:40 pm, observation in the Operating Room #10 revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. An OEC 9900 Elite GE X-Ray machine was stored 2 feet in front of the electric panel.

These deficient practices were confirmed at the time of discovery by a concurrent interview with Staff P and Staff Q.