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Based on record review and interview, the facility failed to ensure automatic emergency lighting in accordance with 2012 NFPA 7.9.3.1.3, 7.10.9.1. This deficient practice could affect all occupants in the event power is lost to the facility.

Findings Include:

1. On December 17, 2024, at approximately 2:45 PM record review revealed the battery backup emergency lighting station inspections are not itemized to ensure every light is tested monthly for 30 seconds as required.

2. On December 17, 2024 at approximately 2:50 PM record review revealed the facility cannot produce documentation to verify the illuminated emergency exit signs are tested monthly and annually as required.

These findings were confirmed through interview with the maintenance director at the time of record review.

Based on observation and interview, the facility failed to ensure hazardous areas are protected by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing. This deficient practice could affect 10 occupants in the event of a hazardous room fire.

Findings Include:
On December 17, 2024 at approximately 1:00 PM observation revealed the large central stores materials management room contains a large amount of combustible supplies and is open to the emergency egress corridor. This will allow smoke heat and fire to escape the storage space and enter the emergency egress corridor.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation, record review and interview, the facility failed to ensure cooking facilities are protected in accordance with 2011 NFPA 96 11.1.1, 11.4, and 2011 NFPA 17A 7.2. This deficient practice could affect all occupants in the event of a fire emergency in the kitchen.

Findings Include:

1. On December 17, 2024, at approximately 12:30 PM record review revealed the facility cannot provide documentation to verify the wet chemical suppression system is being inspected monthly by the owners represented party as required.

2. On December 17, 2024 at approximately 1:30 PM record review revealed the facility cannot produce documentation the kitchen hood system is cleaned at a semiannual interval for moderate cooking operations. This may allow grease laden vapors to build-up in the exhaust system fueling a fire event.

3. On December 17, 2024 at approximately 12:10 PM observation revealed the kitchen exhaust fan was off during cooking operations. The exhaust fan must be on during all cooking operations.

These findings were confirmed thorough interview with the maintenance director at the time of record review and observation.

Based on record review and interview, the facility failed to ensure the gas and vacuum systems are inspected and tests and records are maintained as required by 5.1.14.2.3, 5.1.15, 5.2.14, 5.3.13 and 5.3.13.4 of NFPA 99. This deficient practice could affect all occupants in the event of a medical gas and/or medical vacuum failure.

Findings Include:

On December 17, 2024 at approximately 3:00 PM record review revealed the facility cannot produce documentation to verify medical vacuum is inspected at least annually.

On December 17, 2024 at approximately 3:05 PM record review revealed the facility cannot produce documentation to verify the internal oxygen facility components are inspected at least annually.

These findings were confirmed through interview with the maintenance director at the time of record review.

Based on observation, interview and record review, the facility failed to ensure generators or other alternative power sources are maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4, and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could potentially affect all occupants in the event the generator is affected as a result of poor quality of fuel.

Findings Include:

1. On December 17, 2024 at approximately 2:45 PM record review revealed the facility failed to provide documentation of the required annual diesel fuel sample testing on the facility's diesel fueled generator diesel supply tank.

2. On December 17, 2024 at approximately 2:00 PM observation revealed the facility generator is equipped with maintenance free batteries. The batteries are not being conductance tested monthly as required.

This finding was confirmed by interview with facilities Maintenance Director at the time of record review.

Based on observation and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of NFPA 2012 19.3.2.4 and 2012 NFPA 99 11.3.2.3. This deficient practice could affect 15 occupants in the event of an oxygen fueled fire.

Findings Include:

1. On December 17, 2024 at approximately 11:45 AM observation revealed a 4 cylinder oxygen cylinder holder in the medical surge storage room within 5 feet of combustible materials in storage. This may potentially lead to a oxygen fueled fire in the storage space.

2. On December 17, 2024 at approximately 11:50 AM observation revealed an oxygen cylinder inside the dirty soiled utility room. The dirty soiled utility room is not an acceptable storage location for point of use patient care oxygen cylinders.

3. On December 17, 2024 at approximately 12:00 PM observation revealed the Carbon Dioxide cylinder in the main dining room is unsecured. This may lead to cylinder damage or leaking.

These findings were confirmed through interview with the maintenance director at the time of observation.