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Based on documentation review and staff interview, it was determined that the facility has failed to ensure that the semi-annual inspections of the kitchen hood ventilation and fire suppression system protecting the cooking appliances have been completed. NFPA 96 (11), states that for moderate-volume cooking operations, the hood system and components shall be inspected and maintained semiannually by a properly trained, qualified, and certified company or person. This deficient practice could affect the patients.


Findings Include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during the review of all available documentation for the kitchen hood ventilation and fire suppression system inspection reports, and interview with the Maintenance Supervisor, the facility did not have documentation for 1 of 2 semi-annual kitchen hood suppression system inspections.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2012 NFPA 101, "The Life Safety Code" Sections 19.3.4.1 and 9.6, as well as 2010 NFPA 72, "National Fire Alarm and Signaling Code" sections 29.8.3.4. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affect hospital patients.


Findings include:


On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, observation revealed, that the smoke detector located in the corridor by the bird aviary in the business office waiting area, was installed within 36 inches of a HVAC vent diffuser.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the Fire Alarm system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of 25 of 25 patients.


Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during a records review and an interview with a Maintenance Supervisor, the facility did not have an acceptable fire alarm system out of service policy that included the contact information for the current Deputy State Fire Marshal Division representative.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems 2010 edition. The failure to maintain the sprinkler system in compliance with NFPA 13 (10) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that could affect 25 of 25 patients.


Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, observations revealed the following deficient conditions affecting the facility's fire sprinkler system:

1. It was identified in the fire sprinkler test and inspection documentation dated 07/24/2019 that the facility has quick response type sprinkler heads that are manufactured in 1996 and are older than 20 years. It was also confirmed during the facility walk through that the facility has quick response type sprinkler heads installed throughout the facility as well as some quick response spare sprinkler heads that are also older than 20 years in the spare head box located at the fire sprinkler riser.

2. It was identified in the fire sprinkler test and inspection documentation dated 07/24/2019 that the facility does not have any riser identification and specification signage located on the fire sprinkler riser. It was also confirmed during the walk through that the facility still does not have any riser identification and specification signage located on the fire sprinkler riser.

3. It was observed that the sprinkler escutcheon ring is missing in patient room 204.

4. It was observed that the sprinkler escutcheon ring is missing in the out-patient serves corridor outside of the Exam room 3.

5. The fire sprinkler gauges located on the main fire sprinkler riser have not been replaced or recalibrating every 5 years. The current gauges were manufactured in 2011, and the Maintenance Supervisor could not provide a date when the gauges were last replaced or recalibrating.

6. It was observed that the fire sprinkler system piping located inside of the lower level boiler room known as the "large boiler room" had a natural gas pipeline attached to it.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of 25 of 25 patients.


Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during a records review and an interview with a Maintenance Supervisor, the facility did not have an acceptable fire sprinkler system out of service policy that included the contact information for the current Deputy State Fire Marshal Division representative.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observation and interview with the staff the facility had multiple deficient conditions affecting the facility's electrical system that were not in accordance with the NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 9.1.2 and the NFPA 70 "National Electrical Code" 2011 edition. This deficient practice could affect 25 of 25 patients.


Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, observations revealed that unapproved multi-plug adaptors are being used in patients' rooms 202 through 212.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on review of reports, records and staff interview, it was determined that the facility failed to conduct several fire drills in accordance with the NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 19.7.1.6, during the last 12 months. This deficient practice could affect 25 of 25 patients.


Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during the review of all available fire drill documentation and interview with the Maintenance Supervisor the following deficient conditions were found:

1. The facility failed to vary the times of the fire drills by conducting 3 fire drills during the 8 a.m. hour.

2. The facility failed to vary the times of the fire drills by conducting 3 fire drills during the 3 p.m. hour.

3. The facility failed to verify the DACT during 3 of 4 overnight fire drills.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observation and interview, the facility did not complete the annual fire door inspections in accordance with the requirements of NFPA 101 "The Life Safety Code" 2012 edition and the NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 edition. This deficient practice could affect the safety of 25 of 25 patients.

Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during a records review and an interview with the Maintenance Supervisor, the facility could not provide documentation verifying that the fire door inspection had been completed for all of the fire rated doors located throughout the facility.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observation and interview, the facility did not complete the annual fire door inspections in accordance with the requirements of NFPA 101 "The Life Safety Code" 2012 edition and the NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 edition. This deficient practice could affect the safety of clinic patients.

Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during a records review and an interview with the Maintenance Supervisor, the facility could not provide documentation verifying that the fire door inspection had been completed for all of the fire rated doors located throughout the clinic facility.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observations and staff interview, that the electrical testing and maintenance was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.4. This deficient practice could affect the safety of 25 of 25 patients.

Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during a records review and an interview with the Maintenance Supervisor, the facility could not provide any documentation for the completion of the annual electrical outlet inspection and testing for the electrical outlets located in the patient/resident rooms located throughout the facility.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on observations and staff interview, that the electrical testing and maintenance was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.4. This deficient practice could affect the safety of clinic patients.

Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during a records review and an interview with the Maintenance Supervisor, the facility could not provide any documentation for the completion of the annual electrical outlet inspection and testing for the electrical outlets located in the patient/resident rooms located throughout the clinic facility.


This deficient condition was confirmed by a Maintenance Supervisor.

Based on documentation review and staff interview, the facility failed to test and maintain the emergency generator in accordance with the requirements of the NFPA 101 "The Life Safety Code" 2012 edition (LSC) sections, 9.1.3 and NFPA 110 "Standard for Emergency and Standby Power Systems 6-4, 6-4.1, and 6-4.2.2. This deficient practice could affect the safety of 25 of 25 patients.

Findings include:

On facility tour between 11:00 a.m. and 4:00 p.m. on 02/11/2020, during the review of all available emergency generator maintenance documentation and an interview with the Maintenance Supervisor it was revealed that the facility could not provide documentation for the weekly inspections of the emergency generator for the months spanning from April 2019 through December 2019.


This deficient condition was confirmed by a Maintenance Supervisor.