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Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects the kitchen.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation and documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, 9.6.1.3, 9.6.1.5, and 9.6.1.7

This deficiency affects the facility.

Findings include:

During a tour of the facility, per the annual fire alarm inspection from the facility's fire alarm contractor dated 06/02/2023, the following had not been corrected:

1. Two smoke detectors failed the functional test

2. Six smoke detectors failed the sensitivity test

3. Two heat detectors failed

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide information on the automatic sprinkler anti-freeze systems per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 7.6.1.4, 7.6.1.5, and TIA 10-2

This deficiency affects entire facility.

Findings include:

During a tour of the facility, the facility failed to provide the following:

1. The facility failed to have a placard mounted on the wet system riser feeding the remote antifreeze systems:

This placard shall indicate the number and location of all remote antifreeze systems supplied by that riser.

2. The facility failed to have a placard mounted on the main valves of the antifreeze system. This placard shall indicate the following:

a. The manufacture type and brand of the antifreeze solution

b. The volume of anti-freeze solution used in the system

c. Areas that the anti-freeze loop supplies.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler antifreeze system per requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.4, TIA 11-1, TIA 11-2, TIA 11-3, and TIA 11-4

This deficiency affects 1 of 1 antifreeze system.

Findings include:

During a tour of the facility, the facility failed to provide documentation indicating the existing antifreeze solution had been drained and replaced with the new required premixed antifreeze solution.

A member of the maintenance staff was present when this deficiency was identified.

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* Based on observation, the facility failed to provide heating, ventilating, and air conditioning (HVAC) per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 4.3.12.1.1

This deficiency affects the entire facility.

Findings include:

During a tour of the facility, the surveyor observed the corridor was being used as return air plenum for the HVAC.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6, 4.7.2, 4.7.4, and 4.7.6

This deficiency affects 11 of 12 fire drills.

Findings include:

During a tour of the facility, the facility failed to provide documentation of conducting a fire drill for the first and second quarters of 2023 for any shift. The facility failed to provide documentation of conducting any fire drills for the entire year of 2022. The only fire drill documented was for the third quarter first shift on July 28, 2023.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the emergency generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1
2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 8.4.8, 5.6.5.6, and 5.6.5.6.1

This deficiency affects 1 of 1 generators.

Findings include:

During a tour of the facility, the facility failed to provide the following:

1. Documentation of performing monthly conductance testing on the facility's emergency generator's maintenance-free battery for the past 12 months.

2. A remote manual stop station with a label for the facility emergency generator that has been required for all hospital emergency generators (Level One).

A member of the maintenance staff was present when this deficiency was identified.