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Based on records review and interview, the facility failed to develop procedures for requesting an 1135 Waiver in the event the facility provides care and treatment at an alternate care site identified by emergency management officials.

The findings include:

Review of the facility's policy manual "Emergency Preparedness Plan" on 07/11/2023 revealed the facility did not have policies or procedures on how to request an 1135 Waiver in an emergency to provide care and treatment at an alternate site.

Interview on 07/11/2023 with facility staff revealed that the facility was not familiar with the waiver or the process to request one.

The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1.

Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 57 inches above the floor.

Failure to inspect, maintain, and install the wet chemical extinguishing system in accordance with NFPA 96 increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3. 2010 NFPA 72, 14.1.1

The facility failed to test the fire alarm system as required.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 03/28/2023. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

1) The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)

Observation determined numerous electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected numerous electrical receptacles in the facility.

2) The facility failed to install gas equipment and appliances in accordance with NFPA 54, National Fuel Gas Code.

Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer's installation instructions.
Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.
Use with Casters. Floor-mounted appliances with casters shall be listed for such construction and shall be installed in accordance with the manufacturer's installation instructions for limiting the movement of the appliance to prevent strain on the connection. 19.5.1.1, 9.1.1, NFPA 54 9.6.1.1, 9.6.1.2, 10.12.6

Observation determined the wheeled, gas-fired stove and griddle located on the cooking line in the kitchen was not provided with a restraint system to limit the movement of the appliance to prevent strain on the connections, as required by NFPA 54.

Failure to install gas equipment and appliances in accordance with NFPA 54 increases the risk of injury or death due to fire.

The deficiency affected one (1) of one (1) gas appliance in the Kitchen.