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Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality for the emergency generator. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 6/19/19, at 11:23 am revealed documentation was not provided to verify the diesel fuel for the generator tank was tested annually for quality.

In an interview on 6/19/19, at 11:23 am, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

Based on record review and staff interview, the facility failed to test OR battery backup emergency lights annually and monthly. This condition created the potential for the failure of emergency lighting.

Findings are:
Record review on 6/19/19 at 11:48 am revealed an annual 90 minute test of all battery backup lights in the OR was not documented since 2/2018. A monthly function test was not documented for 4/2019.

In an interview on 6/19/19 at 11:48 am, Maintenance A confirmed the testing was not completed.

Based on observation and staff interview, the facility failed to separate a hazardous area with a smoke resistive door. This condition would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 6/19/19, at 12:04 pm revealed the Central Supply corridor door did not positively latch when self-closed.

In an interview on 6/19/19, at 12:04 pm, Maintenance A acknowledged the door did not latch.

Based on record review and staff interview, the facility failed to conduct a monthly visual inspection for components of the range hood fire-extinguishing system. This condition did not ensure that all system components were in position and intact, that the system was not obstructed or damaged, and increased the potential that the suppression system would not operate as designed during a cooking fire.

Findings are:
Record review on 6/19/19, at 11:22 am revealed documentation was not provided to verify that monthly visual range hood fire-extinguishing system inspections were conducted by the facility for the Kitchen range fire-extinguishing system.

In an interview on 6/19/19, at 11:22 am, Maintenance A confirmed the inspections were not documented.

Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

NFPA 96, 2011, 10.2.6 Automatic fire-extinguishing systems shall be installed in
accordance with the terms of their listing, the manufacturer's
instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A, 2009, 7.2 Owner ' s Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in
accordance with the manufacturer ' s listed installation and
maintenance manual or the owner ' s manual.
7.2.2 At a minimum, this " quick check " or inspection shall
include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that
might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected
physically or electronically to ensure it is in the operable
range.
(7) The nozzle blowoff caps, where provided, are intact and
undamaged.
(8) Neither the protected equipment nor the hazard has not
been replaced, modified, or relocated.

Based on record review and staff interview, the facility failed to specify all required parties to be contacted in the event a fire watch was initiated when the fire sprinkler system was out of service for more than 10 hours in any 24-hour period. This practice would not provide notification of the cause of the fire watch to all parties that were required.

Findings are:

Record review on 6/19/19, at 11:21 am of the fire watch procedures revealed the policy lacked that the facility's insurance carrier, and state licensing would be notified of the impairment.

In an interview on 6/19/19, at 11:21 am, Maintenance A confirmed the fire watch policy did not make this specification.

NFPA 25, 2011, 15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited
to, system leakage, interruption of water supply, frozen or
ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action
shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in
Section 15.5.
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by
the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator
shall be responsible for verifying that the following procedures
have been implemented:
(6) The insurance carrier, the alarm company, property
owner or designated representative, and other authorities
having jurisdiction have been notified.

Based on record review and staff interview, the facility failed to inspect and test fire doors annually throughout the facility. This condition would allow the spread of fire through faulty fire doors that would otherwise contain a fire.

Findings are:

Record review on 6/19/19, at 11:28 am revealed a preventative maintenance plan to inspect and test fire doors annually was not provided for review.

In an interview on 6/19/19, at 11:28 am, Maintenance A confirmed the fire door testing was not implemented.

NFPA 80, 2010, 5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not
less than annually, and a written record of the inspection shall
be signed and kept for inspection by the AHJ.

5.2.4 Swinging Doors with Builders Hardware or Fire Door
Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from
both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the
door or frame.
(2) Glazing, vision light frames, and glazing beads are intact
and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible
threshold are secured, aligned, and in working order
with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4
and 6.3.1.7.
(6) The self-closing device is operational; that is, the active
door completely closes when operated from the full
open position.
(7) If a coordinator is installed, the inactive leaf closes before
the active leaf.
(8) Latching hardware operates and secures the door when
it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation
are not installed on the door or frame.
(10) No field modifications to the door assembly have been
performed that void the label.
(11) Gasketing and edge seals, where required, are inspected
to verify their presence and integrity.

Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality for the emergency generator. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 6/19/19, at 11:23 am revealed documentation was not provided to verify the diesel fuel for the generator tank was tested annually for quality
.
In an interview on 6/19/19, at 11:23 am, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.