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Based on record review and staff interview, the facility failed to conduct a monthly visual inspection for components of the range hood suppression system. This condition did not ensure that all system components were in position and intact, that the system was not obstructed or damaged, and increased the potential that the suppression system would not operate as designed during a cooking fire.

Findings are:
Record review on 2/6/18, at 1:17 pm revealed documentation was not provided to verify that monthly visual range hood suppression system inspections were conducted by the facility for the Kitchen range hood suppression system.

In an interview on 2/6/18, at 1:17 pm, Maintenance A confirmed the inspection was not implemented.

Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

NFPA 96, 2011, 10.2.6 Automatic fire-extinguishing systems shall be installed in
accordance with the terms of their listing, the manufacturer's
instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A, 2009, 7.2 Owner ' s Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in
accordance with the manufacturer ' s listed installation and
maintenance manual or the owner ' s manual.
7.2.2 At a minimum, this " quick check " or inspection shall
include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that
might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected
physically or electronically to ensure it is in the operable
range.
(7) The nozzle blowoff caps, where provided, are intact and
undamaged.
(8) Neither the protected equipment nor the hazard has not
been replaced, modified, or relocated.

Based on record review and staff interview, the facility failed to include all required parties to be contacted in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period in the facility fire watch policy. This practice would not provide notification of the condition to all those that were required.

Findings are:

Record review on 2/6/18, at 1:35 pm of the automatic sprinkler system fire watch procedures revealed the policy lacked that the facility's insurance carrier would be notified of impairment.

In an interview on 2/6/18, at 1:35 pm, Maintenance A confirmed the fire watch policy did not make this specification.

NFPA 25, 2011, 15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited
to, system leakage, interruption of water supply, frozen or
ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action
shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in
Section 15.5.
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by
the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator
shall be responsible for verifying that the following procedures
have been implemented:
(6) The insurance carrier, the alarm company, property
owner or designated representative, and other authorities
having jurisdiction have been notified.

Based on record review and staff interview, the facility failed to provide a complete fire procedure that addressed all aspects of fire response and evacuation. This condition would affect patient evacuations throughout the facility.
Findings are:

Record review on 2/6/18, at 1:39 pm of the facility fire procedures revealed the evacuation procedures did not specify evacuation order by proximity to the fire. Specifically, patients would be rescued from the room of fire origin, on both sides of the room of fire origin, and across the hall.

In an interview on 2/6/18, at 1:39 pm, Maintenance A confirmed the information was not present in the fire procedure.

NFPA 101, 2012, 19.7.2.2 Fire Safety Plan. A written health care occupancy fire
safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Based on record review and staff interview, the facility failed to conduct annual inspection and testing of fire doors in the facility. The deficient practice did not ensure the fire doors would operates as designed to prevent fire from spreading beyond the room or area of origin.

Findings are:

Record review on 2/6/18, at 1:20 pm revealed a preventative maintenance plan to inspect and test fire doors annually was not provided for review.

In an interview on 2/6/18, at 1:20 pm, Maintenance A confirmed fire door testing had not been implemented.

NFPA 80, 2010, 5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not
less than annually, and a written record of the inspection shall
be signed and kept for inspection by the AHJ.