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Based on record review and interview with staff, it was determined the facility did not have documented evidence that the kitchen hood system was inspected semi-annually in accordance with NFPA 96. Failing to inspect the kitchen hood entire fire extinguishing system semi-annually could allow a build-up of grease and provide fuel for a fire. A fire in the kitchen has potential to harm the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 "Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and a exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months."

Findings Include:

During the review of facility documentation, the fire suppression system for the kitchen hood system was requested on March 3-6, 2025. The facility was unable to provide documented evidence that the fire extinguishing system was inspected in accordance with NFPA 96 Edition. The last Simi annual test was conduted on December 27, 2023.

Employees #2, and #4 confirmed during the exit conference on March 6, 2025, that there was no documentation that the fire extinguishing system was inspected in accordance with NFPA 96, 2011 Edition, semi-annually.

Based on Document review the facility failed to make repairs to a failed fire alarm panel. Failure tomaintain the fire alarm system could cause harm to staff and residents during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "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, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and fore 1 year thereafter. CMS requires 3 years.
NFPA 72 Chapter 14, section 14.2.5 Releasing Systems.
Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection amd service.

Findings include:

During review of the facility's documentation on March 3-6, 2025, There was no documentation of a passing annual test of the following sysytems:
1.The fire alarm system had an annual test in August 2024 with ten failed batteries, two non-work horn/strobes and thirty eight mislabeled smoke detectors. The facility did placement to the batteries but no re-test was documented and non of the other repairs were completed.

Employees #2, and #4 confirmed during the exit conferance that the facility failed to make repairs to fire alarm alarm system for over six months

Based on observation it was determined the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8 Obstructions to Sprinkler Discharge Pattern Development. Section 8.6.5.2.1.1 Continuous or noncontiguous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

Findings include:

A facility tour conducted on Mar 3-6, 2025, revealed that a sprinkler head was not appropriately installed during a recent building modification. The sprinkler head was lying directly above the drop ceiling tile with a danger tag attached. The ceiling tile would prevent the sprinkler from actuating in the event of a fire. This head was located just prior to the door of the kitchen back hallway

Employees #2 and #4 confirmed during the exit conference that the sprinkler head in the kitchen back hallway was not installed correctly. The sprinkler head was installed directly above the drop ceiling tile during a recent building modification. The ceiling tile would prevent the sprinkler from actuating in a fire.

Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth.
6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazard Basic Minimum Extinguisher Rating Maximum Travel Distance to Extinguishers
(moderate) 20-B 50 ft

Findings include:

Observations made while on tour on March 4, 2025, revealed there was not a fire extinguisher installed within 50 feet of the generator.

Employees #2 and #4 confirmed on March 6th, 2025 that newer generator did not have an extinguisher within 50 feet from the generator.

Based on observation, it was determined the facility failed to fill penetrations in a smoke barrier in the entire main hospital. Failing to fill the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm if a fire were to occur.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations during a facility tour conducted on March 30-6, 2025, revealed a large hole in the drywall between rooms #1106 and #1118, the entire wall being a smoke barrier.
(note) there were other areas with holes in the fire or smoke barriers, but these were corrected by the facility before the exit.

During the exit conference, Employees, #2 and #4 confirmed knowledge of the holes in the smoke barriers between rooms #1106 and #1118.

Based on Observation, it was determined that the facility allowed the use of a power strip but did not mount it to the equipment in the operating rooms. There was also one non-rated power strip in the operating room. Failure to properly use power strips and outlets could lead to electrical overload or fire, harming the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

CMS S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as a reference for healthcare surveyors as they survey the physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation.
If line-operated medical equipment is used in a patient care room/area inside the patient care vicinity:
1. UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly
2. Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
3. Power strips cannot be used for non-medical equipment
If line-operated medical equipment is used in a patient care room/area outside the patient care vicinity:
UL power strips could be used for medical & non-medical equipment with precautions as described in the memo
1. Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
2. Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363
3. If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity:

Findings include:

Observations made during the tour from Mar 3-6, 2025, revealed that operating room #3 had the following:
1. a power strip that was not mounted to a rack, table, pedestal, or cart-mounted and tested medical equipment assembly
2. One power strip was not UL 1363A or UL 60601-1 rated being used

Based on Observation the facility failed to secure medical gas Helium and Oxygen cylinders in the med gas room, as well as untreated combustible items in the med gas room Failing to secure compressed medical gas cylinders could cause harm to the patients and staff. Storing combustibles item in the med gas room could result in a fire in the room

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.3 Cylinder and Container Storage Requirements. 11.3.2 Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour

Findings include:

Observations while on tour March 3-6, 2025 revealed the following:
1. Two (2) unsecured Helum cylinders in the storgare area of the med gas room and numerius small oxygen cylindars with the chain approx 2 in from the floor.
2. An untreated woodedn book case being used for storage in the med gas room

Employees #2 and #4 conformed at the exit interview that the med gas room had unsecured cylindars and untreated wood storred inside the room