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Based on review of documentation, the facility failed to maintain the kitchen hood per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 11.4, Table 11.4, and 11.6

This deficiency affects the kitchen hood.

Findings include:

During a tour of the facility, the facility failed to provide documentation of a kitchen hood cleaning being conducted for January 2024. The facility did provide documentation of kitchen hood cleaning on 07/09/2024.

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 a fire alarm cellular dialer per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 26.6.2.2, 26.6.3.1.4.1, and 10.12.1

This deficiency affects the comunication of the fire alarm system.

Findings include:

During a tour of the facility, the surveyor observed that the newly installed cellular dialer was not the required UL 864 model for health care. The installed dialer model was UL S2576. This cellular dialer could not be tested, per the fire alarm company.

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 maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 14.2.1

This deficiency affects the automatic sprinkler system.

Findings include:

During the review of the documentation, the facility failed to provide documentation of conducting the automatic sprinkler internal pipe inspection within the past 5 years.

A member of the maintenance staff and the administrator were 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 2 of 12 fire drills.

Findings include:

During a tour of the facility, the facility failed to provide the documentation of fire drills being conducted for the 2023's fourth quarter for the second and third shifts (October and November of 2023).

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

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Based on observation, the facility failed to maintain the area where smoking is permitted per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency affects 1 of 2 smoking areas.

Findings include:

During a tour of the facility, the surveyor observed the smoking area located outside of the Administration Hall's rear egress door was missing the metal container with a self-closing lid.

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