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Based on observation and interviews, the facility failed to ensure the cooking facilities were protected as required by NFPA 96. Specifically, the facility failed to ensure the kitchen range hood provided proper coverage for the capture and removal of grease-laden vapors.

Findings:

1. A tour of the facility's kitchen was conducted on 07/26/22 at 10:20a.m. and the following observation was made:

The facility purchased a new kitchen range. The commercial cooking hood did not provide a horizontal distance of not less than 6 inches beyond the edge of the front, left and right side of the cooking surface.

Note: The range extended past the right side and front of the kitchen hood approximately 10 to 12 inches.

2. The maintenance supervisor and the Chief Clinical Officer were present during the tour of the kitchen and acknowledged the kitchen range was not completely under the kitchen hood.

NFPA Standard: NFPA 96 (1998 Edition) 2.2 Hood Size. Hoods shall be sized and configured to provide for the capture and removal of grease-laden vapors.

International Mechanical Code (2003 Edition) 507.12 The inside lower edge of canopy-type commercial cooking hoods shall overhang or extend a horizontal distance of not less than 6 inches (152 mm) beyond the edge of the cooking surface, on all open sides.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system.

Findings:

1. The facility records were reviewed on 07/26/22 at 1:20 p.m. The most recent annual sprinkler inspection document was dated 12/01/21.

The facility failed to provide documentation the quarterly sprinkler inspections were performed for the first and second quarters of 2022.

2. The maintenance supervisor and the Chief Clinical Officer were present during the record review and stated they were not aware that the quarterly sprinkler inspections were required.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke.

Findings:

1. A tour of the facility was conducted on 07/26/22, between 8:45a.m. and 3:00p.m. The following observations were made:

First Floor

a. The door to the men's restroom (across from the Chief Clinical Officer's office) was noted to have a hole in the door where old hardware had been removed.

b. The door to the dish room was noted to have a hole in the door where old hardware had been removed

Second Floor

a. The door to the drug room had a hole in the door where old hardware had been removed.

2. The maintenance supervisor and the Chief Clinical Officer was present during the tour of the facility and acknowledged the holes in the corridor doors.

Based on observation and interview, the facility failed to maintain smoke barrier walls to provide at least a one-hour fire resistance rating as required.

Findings:

1. A tour of the facility was conducted on 07/26/22, at 11:10a.m., the following observation was made.

Supply room smoke wall

a) one unsealed penetration, associated with several computer wires was observed above the smoke door in the supply room.

2. The maintenance supervisor and the Chief Clinical Officer were present during the entire tour of the facility and they acknowledged the unsealed penetration in the smoke wall.

Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.
8.3, 19.3.7.3, 19.3.7.5

Based on observation and interview, the facility failed to ensure the electrical system was properly installed and maintained to ensure the safety of all staff.

Findings:

1. A tour of the facility was conducted on 07/26/22, at 10:20a.m. The following observations were made:

Kitchen

a. A mixer and a food processor electrical were observed on the counter top. The outlet was not ground fault circuit interrupt (GFCI).


2. The maintenance supervisor and the Chief Clinical Officer were present during the tour of the kitchen and acknowledged the electrical outlets were not Ground fault circuit interrupt (GFCI).