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Based on document review and staff interview, the facility failed to test battery-powered emergency lighting in accordance with the 2012 NFPA 101, Life Safety Code. Failure to test battery-powered lighting as required could result in system failure during an emergency. The deficiency may cause harm to staff, patients, and visitors during an emergency. The findings were:

Document review on 08/17/2022 starting at 10:30 AM revealed that no records for the required monthly 30-second test of battery-powered emergency lighting was available.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator and facility manager at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 7.9.3.1.1(1) and 7.9.3.1.2(5)

Based on observation and staff interview, the facility failed to protect cooking equipment in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to properly protect cooking equipment could lead to equipment damage or improper protection by fire suppression systems, resulting in injury or death during an emergency. The deficiency affected the kitchen and all staff within. The findings were:

Observation on 08/17/2022 at 9:50 AM in the kitchen revealed multiple wheeled gas-fired cooking appliances located beneath the grease hood and fire suppression system. Further observation revealed that no means was provided to ensure that the equipment is returned to the approved location beneath the fire suppression system after being moved for service or cleaning.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated he was not aware of the requirement.

Interview with the administrator and facility manager at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections 19.3.2.5.5 and 9.2.3
2011 NFPA 96, Section 12.1.2.3

Based on document review and staff interview, the facility failed to test and maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain fire alarm systems as required could result in system failure or malfunction during an emergency. The deficiencies could impact all patients, staff, and visitors. The findings were:

Document review on 08/17/2022 starting at 10:30 AM revealed that the facility did not have documentation to demonstrate that the following testing had been performed:

1. Semi-annual testing of sealed lead acid batteries for the fire alarm system. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that semi-annual testing had been performed during the first half of the year.

2. Semi-annual battery load voltage testing. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that semi-annual testing had been performed during the first half of the year.

3. Quarterly water flow alarm device testing. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that quarterly testing had been performed during the first half of the year.

4. Quarterly supervisory signal device testing. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that quarterly testing had been performed during the first half of the year.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator and facility manager at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 18.3.4.1
2010 NFPA 72, Sections 13.2.6.1 and 14.6.2.4 and Tables 14.3.1, 14.4.5
2011 NFPA 25, Table 5.1.1.2

Based on document review and staff interview, the facility failed to test and maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain fire alarm systems as required could result in system failure or malfunction during an emergency. The deficiencies could impact all patients, staff, and visitors. The findings were:

Document review on 08/17/2022 starting at 10:30 AM revealed that the facility did not have documentation to demonstrate that the following testing had been performed:

1. Semi-annual testing of sealed lead acid batteries for the fire alarm system. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that semi-annual testing had been performed during the first half of the year.

2. Semi-annual battery load voltage testing. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that semi-annual testing had been performed during the first half of the year.

3. Quarterly water flow alarm device testing. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that quarterly testing had been performed during the first half of the year.

4. Quarterly supervisory signal device testing. Documentation was available to demonstrate testing had been performed on 07/22, but no additional information was available to establish that quarterly testing had been performed during the first half of the year.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator and facility manager at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 19.3.4.1
2010 NFPA 72, Sections 13.2.6.1 and 14.6.2.4 and Tables 14.3.1, 14.4.5
2011 NFPA 25, Table 5.1.1.2

Based on observation and staff interview, the facility failed to maintain fire sprinkler systems in accordance with the 2012 NFPA 101. Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to maintain fire sprinkler systems as required could result in injury or death due to inadequate response to a fire. The deficiency affected two (2) of numerous storage areas throughout the facility.

The findings were:

Observation on 08/17/2022 at 10:10 AM in storage 818 revealed a large number of cardboard boxes stacked from the floor to within six (6) inches of the sprinkler heads throughout the space.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator and facility manager at the time of exit acknowledged the deficiency.

REF: 2011 NFPA 25, Sections 5.2.1.2 and 5.2.1.3

Based on observation and staff interview, the facility failed to protect gas-fired equipment in accordance with the 2012 NFPA 101, Life Safety Code, and the 2012 NFPA 54, National Fuel Gas Code. Failure to maintain gas-fired equipment could lead to system damage and failure, resulting in injuries to staff or residents. The deficiency affected the kitchen, and all staff working within.

The findings were:

Observation on 08/17/2022 at 9:50 AM in the kitchen revealed a gas-fired oven and combination oven. Further observation revealed that these appliances were on casters, and that the required restraint to protect the flexible gas piping when the appliance is moved for service or cleaning had been disconnected.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator and facility manager at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 54, Section 9.6.1.2