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Based on review of documentation, the facility failed to provide documentation on the testing of the emergency lighting per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.3.1.1 (1) (3) (5)

This deficiency affects all emergency light fixtures.

Findings include:

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

1. The monthly testing of the following:

a. Emergency light fixtures on the generator

b. Battery powered emergency light fixtures

2. The annual functional testing of the battery powered emergency light fixtures

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 provide documentation of the visual monthly inspections of the exit signs per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.9.1

This deficiency affects all exit signs.

Findings include:

During a tour of the facility, the facility failed to provide documentation of the monthly visual inspections on any of the exit signs.

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 kitchen hood and the extinguishing system per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 10.2.6 (4), 11.2.1, 11.4, Table 11.4, 11.6, 12.1.2.2, 12.1.2.3 and 12.22.3.1
2012 NFPA 101, 19.3.2.5.1 and 9.2.3
2009 NFPA 17A, 7.2.1, and 7.2.2

This deficiency affects the kitchen.

Findings include:

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

1. Documentation of the monthly inspections for the kitchen hood's automatic fire-extinguishing system. The last documented inspection was dated 04/2019

2. Documentation of the semi-annual (6 month) inspections for the kitchen hood's automatic fire-extinguishing system. The automatic fire-extinguishing system was last inspected on 04/2019

3. Documentation of the semi-annual (6 month) kitchen hood inspection and cleaning. The only documentation the facility could provide was dated 07/19/2023

4. 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 review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h), and 14.4.5.3.2

This deficiency affects all of the smoke detectors.

Findings include:

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

1. Conducting semi-annual visual inspections on the smoke detectors within the past 12 months

2. A smoke detector sensitivity test report completed within the past two years. No documented sensitivity test was provided

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 1 of 1 anti-freeze system.

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 system:

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

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 systems per requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.1.1.1.6, 5.3.4, TIA 11-1, TIA 11-2, TIA 11-3, TIA 11-4, 5.2.4.2, 4.1.4.1, 4.1.4.2, 5.2.4.1

This deficiency affects all components of the sprinkler system.

Findings include:

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

1. Indicating the existing antifreeze solution had been drained and replaced with the new required premixed antifreeze solution

2. The annual inspection for the anti-freeze sprinkler system

3. The weekly inspections of the dry sprinkler system riser gauges

4. The monthly inspections of the wet sprinkler system riser gauges

5. That the dry sprinklers installed in 2009, located in the walk-in freezer had been replaced or a representative sample tested within 10 years of installation.

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 all 2nd shift fire drills.

Findings include:

During a tour of the facility, the facility failed to provide 2nd shift fire drills for all quarters within the last 12 months. According to staff the facility has two shifts; 1st shift 7 a.m. - 7 p.m. and 2nd shift 7 p.m. - 7 a.m.

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 fire doors per the requirements of:

2012 NFPA 101, 19.7.6, 4.6.12, and 8.3.3.1
2010 NFPA 80, 5.2, and 5.2.3
S&C 17-38-LSC

This deficiency affects 3 of 3 fire doors.

Findings include:

During a tour of the facility, the facility failed to provide documentation of its annual fire door inspection and testing for the past 12 months.

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 piped medical gas per the requirements of:

2012 NFPA 99, 5.1.14.2.1, 5.1.14.2.2, and 5.1.15

This deficiency affects all of the medical gas and vacuum systems.

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

1. Periodic maintenance schedule to maintain the medical gas, vacuum, WAGD, and medical support gas systems

2. An inventory of these systems

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 piped medical gas and vacuum systems per the requirements of:

2012 NFPA 99, 5.1.14.2.3

This deficiency affects all of the medical gas and vacuum systems.

During a tour of the facility, the facility failed to provide documentation of the annual inspection for the piped medical gas and vacuum systems for the past 12 months.

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 Level 1 EES diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, and 6.4.4.1.1.3
2010 NFPA 110, 8.3.7, 8.4.1, 8.4.2, 8.3.4, 8.4.9, 8.3.8, and 8.3.7.1

This deficiency affects 1 of 1 emergency generator.

Findings include:

During a tour of the facility, the facility failed to provide the following documentation for the emergency generator:

1. Weekly visual inspections

2. Monthly exercise for a minimum of 30 minutes with the available load

3. Annual diesel supplemental 1.5-hour load test (last documented on 12/16/2019)

4. Level 1 EPSS 4-hour load bank test every 36 months (last documented on 11/19/2018)

5. Annual fuel quality test approved by ASTM standards (last documented on 12/16/2019)

6. Monthly battery testing and recording of the electrolyte specific gravity OR the conductance

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 ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

This deficiency affects entire facility.

Findings include:

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

1. The qualifications and training of the facility's training personnel on handling oxygen cylinders.

2. Continuing education for their personnel that handle oxygen cylinders

3. Training personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases on the risks associated with their handling and use.

4. A continuing education program for staff that handle oxygen cylinders to include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.

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