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Based on observation and staff interview, the facility failed to ensure the kitchen deep fryer was properly separated from the open flames of the kitchen range as required by NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Findings:

1. A tour of the facility was conducted on 08/07/2024 from 2:00 p.m. to 3:55 p.m., and the following observation was made:

The deep fryer was located directly against the left side of the kitchen range. An eight inch high steel or tempered glass shield was not provided to separate the deep fryer from the surface flames of the kitchen range.

2. The maintenance supervisor was present during the tour of the facility and acknowledged the deep fryer was not separated from the kitchen range surface flames.

NFPA 96, 1998 Edition, 9-1.2.3 states:
All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.
Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.

Based on observation and staff interview, the facility failed to maintain ceilings and walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 08/07/2024 from 2:00 p.m. to 3:55 p.m., and the following observations were made:

a. 2 unsealed ceiling penetrations were observed in the kitchen.

b. 2 unsealed wall penetrations were observed in x-ray hall by the electrical box and time clock.

c. An unsealed wall penetration was observed in the fire wall above the fire doors leading into the clinic area.

d. An unsealed ceiling penetration was observed near the ER registration desk.

e. An unsealed ceiling penetration was observed in the public bathroom.

f. 2 unsealed penetrations were observed in the supply closet located on the ER central hall.

2. The maintenance supervisor was present during the tour of the facility and acknowledged the problems with the unsealed areas. He stated he would make the repairs as soon as possible.

Based on observation and interview, the facility failed to enforce required smoking regulations. Findings:

1. A tour outside of the facility was conducted on 08/07/2024 from 2:00 p.m. to 3:55 p.m., and it was observed that the generator did not have a required no smoking sign on it.

2. The maintenance supervisor and administrator were present during the tour and acknowledged that there was not a no smoking sign and stated he would put one up asap.

Based on record review, observation, and staff interview, the facility failed to properly maintain and test the generator as required by NFPA 99. In the event of an electrical outage, the facility could not be assured the generator would power the designated outside lights for safe evacuation during an emergency. Findings:

1. During the record review of the generator on 08/07/2024 at 1:00 p.m., it was determined there was no documentation the maintenance supervisor was performing an weekly inspection on the generator.

2. The maintenance supervisor was interviewed and stated he tested the generator monthly but was unaware that a weekly visual inspection was to be performed and documented.

Based on observation and staff interview, the facility failed to provide safe storage for each oxygen cylinder as required by NFPA 99. Findings:

1. During a tour of the facility on 08/07/2024 from 2:00 p.m. to 3:55 p.m., the following observations were made:

There were no empty or full oxygen bottles signs. The full and empty bottles were also mixed together.

2. The maintenance supervisor was present during the tour of the facility on and acknowledged the oxygen cylinders were not labeled and were mixed together.