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Based on document review and interview, the provider failed to conduct the required every six-months inspection of the exhaust ductwork for the range hood. The records regarding the kitchen hood indicated a ductwork cleaning had been done in September 2021 and September 2022. Findings include:

1. Document review on 3/21/23 at 8:30 a.m. of the kitchen hood system records indicated the fire suppression system for the kitchen hood had been inspected every six months, in July 2022 and January 2023. The hood ductwork had been cleaned in September 2021 and September 2022. The kitchen hood exhaust ductwork system must be inspected for grease buildup and cleaned as needed not less than every six months. There was no further documentation indicating other required inspections had taken place.

Interview with the director of plant operations at the time of the document review confirmed that finding. He stated he was unaware of the every six-month ductwork inspection requirement.

The deficiency affected one of numerous kitchen hood system requirements.

Based on document review and interview, the provider failed to the ensure the automatic fire sprinkler system was tested, inspected, and maintained in accordance with NFPA 25 for two of numerous maintenance and testing requirements (headbox with spare sprinklers or signage for CV and main drain). Findings include:

1. Document review at on 3/21/23 at 9:00 a.m. of the fire sprinkler system inspection report dated 2/27/23 prepared by Building Sprinkler Inc. revealed no headbox with spare sprinklers or CV and main drain signs for the Legacy building.

Interview with the director of plant operations at the time of the above observations confirmed those findings. He indicated he was unaware of the deficient items noted in the sprinkler system maintenance report from Building Sprinkler Inc.

This deficiency has the potential to affect all occupants in the building.

Based on observation, document review, and interview, the provider failed to ensure the automatic fire sprinkler system was tested, inspected, and maintained in accordance with NFPA 25 for three of numerous maintenances and testing requirements (five-year internal obstruction investigation, backflow preventer annual testing, and NFPA 25 copy on site). Findings include:

1. Observation at 4:30 p.m. on 3/20/23 noted the 4-inch isolation shut-off valve for the backflow preventer was frozen in position and needed to be replaced in order to perform a backflow preventer test. A tag on the isolation valve was dated 8/11/22. Document review at on 3/21/23 at 9:00 a.m. of the fire sprinkler system inspection report dated 2/27/23 prepared by Building Sprinkler Inc. revealed no indication that a current annual backflow preventer inspection had been performed. The last documented successful backflow preventer inspection was dated 7/19/21.

2. Document review at on 3/21/23 at 9:00 a.m. of the fire sprinkler system inspection report dated 2/27/23 prepared by Building Sprinkler Inc. revealed no indication that a current five-year internal obstruction investigation had been conducted. The last five year internal obstruction inspection had been performed in 2017. Every five years an obstruction investigation shall be conducted on the sprinkler apparatus. The investigation is to be conducted to ensure limited presence of foreign matter or obstructions within the sprinkler. The presence of obstructions or foreign matter may otherwise jeopardize the functionality of the fire sprinkler system.

3. Observation on 3/21/23 at 10:30 a.m. revealed there was not a copy of NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-Based Fire Protection Systems on site for reference.

Interview with the director of plant operations at the time of the above observations confirmed those findings. He indicated he was unaware of the deficient items noted in the sprinkler system maintenance reports from Building Sprinkler Inc.

This deficiency has the potential to affect 100 percent of the building occupants.

Based on observation and interview, the provider failed to maintain the required clearance for one randomly room (electrical circuit panels) in mechanical rooms. Findings include:

1. Observation on 3/21/23 at 8:30 a.m. revealed the electrical circuit panel for the Pro Rehab building at 1552 Dakota Ave. S had a six foot tall fiberglass ladder leaning against the front of the circuit panel box in the furnace room.

2. Observation on 3/21/23 at 8:45 a.m. revealed the Pro Arts building at 530 Iowa Ave. SE had copious amount of items (file cabinets, printer, ceiling tiles) stored on the floor in front of the circuit panel boxes in the mechanical room. The floor was not marked to help maintain the required 36 inches of clearance.

Interview with the director of plant operations at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for the maintenance of electrical equipment.