Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
06/05/2024 | Fire/Life/Safety | W7C7 | K0324 | E | 3 | COOKING FACILITIESCooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
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06/05/2024 | Fire/Life/Safety | W7C7 | K0521 | F | 3 | HVACHVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
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06/05/2024 | Fire/Life/Safety | W7C7 | K0741 | D | 3 | SMOKING REGULATIONSSmoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4
(Note smoking tower disposal receptacles are not ashtrays)
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06/05/2024 | Fire/Life/Safety | W7C7 | K1150 | F | 3 | SECURITY MANAGEMENTThis chapter shall apply to new and existing health care facilities. A health care facility shall have a security management plan. The scope, objectives, performance, and effectiveness of the security plan shall be tested at a frequency shown to be necessary by review of the security vulnerability assessment
(SVA) in accordance with Section 13.3.
NFPA 99 (2015 Edition)
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06/05/2024 | Standard | W7C7 | F0578 | D | | REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR | |
06/05/2024 | Standard | W7C7 | F0641 | D | | ACCURACY OF ASSESSMENTS | |
06/05/2024 | Standard | W7C7 | F0677 | D | | ADL CARE PROVIDED FOR DEPENDENT RESIDENTS | |
06/05/2024 | Standard | W7C7 | F0679 | D | | ACTIVITIES MEET INTEREST/NEEDS EACH RESIDENT | |
06/05/2024 | Standard | W7C7 | F0685 | D | | TREATMENT/DEVICES TO MAINTAIN HEARING/VISION | |
06/05/2024 | Standard | W7C7 | F0688 | D | | INCREASE/PREVENT DECREASE IN ROM/MOBILITY | |
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