HospitalInspections.org

Based on record review and staff interview, the facility staff failed to maintain the range hood ventilation system in accordance with NFPA 96 standards. The facility census was five.

Record review on 12/5/23 of the range hood inspection form dated 10/24/23, showed a note that stated "Big fan for fryer hood blades are locked up and turned of on roof".

During an interview on 12/5/23 at 1:08 P.M., the Maintenance Director said that the facility has not repaired the range hood fan.

NFPA 96 section 4.1.3 states "The following equipment shall be kept in working condition:
(1) Cooking equipment
(2) Hoods
(3) Ducts (if applicable)
(4) Fans
(5) Fire-extinguishing equipment
(6) Special effluent or energy control equipment

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was five.

1. Observations on 12/4/23-12/6/23, during the facility tour, showed multiple areas of the building did not have sprinkler coverage. Observation showed those areas without sprinkler coverage did not have smoke detectors. Areas without smoke detectors include exit corridors on the 1st, 2nd and 3rd floors, exit stairwells, patient rooms and areas where patients, staff and visitors congregate.

During an interview on 12/5/23 at 9:00 A.M., The Maintenance Director confirmed the observations.

National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states:


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

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on interview and national standards the facility failed to enssure all staff were trained on the activation of the kitchen hood and the location of the manual pull. The facility census was one Acute Care patient, one Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patient and three Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of three.

Findings included:

1. During an interview on 12/04/23 at 2:35 PM, Staff K, Dietary Manager, Staff L, Dietary Staff, and Staff M, Dietary employee were asked about the location of the manual pull station for the main hood extinguishment system. The three employees on duty at the time did not know the location of the manual pull.

2. The National Fire Protection Association (NFPA) 2011 edition of 96 Fire Protection of Commercial Cooking, showed:

10.2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and
portable fire extinguishers as secondary backup.
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be
activated prior to using the fire extinguisher.
10.5 Manual Activation.
10.5.1 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.
10.5.1.1 At least one manual actuation device shall be located a minimum of 3 m (10 ft) and a maximum of 6 m (20 ft) from the protected kitchen appliance(s) within the path of egress.
10.5.7 Instruction shall be provided to employees regarding the proper use of portable fire extinguishers and the manual
activation of fire-extinguishing equipment.

Based on observation and interview the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was five.

1. Observations on 12/4/23-12/6/23 , during the Life Safety Code tour, showed window blinds throughout the facility without identification that showed th/em as being flame retardant.

During an interview on 12/6/23 at 10:30 A.M., the Maintenance Director said that he did not know if the blinds had a rating.


NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. This facility census was five.

1. Review of the facility's inspection, testing and maintenance records showed the last annual inspection of the fire egress doors and non rated doors was 2/7/22.

During an interview on 12/5/23 at 1:00 P.M., the Maintenance Director said he did not have recent annual door inspections.

NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.