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Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in three instances, affecting two of eleven smoke compartments.

Findings include:

1. Observation on December 9, 2024, revealed the following hazardous area enclosure deficiencies:

a) 10:54 the receiving room door was being held open with an unapproved hold-open device (wooden wedge);
b) 10:55 a.m., the receiving room door was unable to self-close and latch in its frame when tested;
c) 11:04 a.m., revealed the purchasing room door equipped with an astragal, which prevented the inactive door from closing and latching before the active door closes and latches, coordinating devices shall be used. In accordance with NFPA 80, 2010 Edition, 6.4.1.2 and 6.4.1.2.1.

Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain cooking equipment from unauthorized use in one instance, affecting one of eleven smoke compartments.

Findings include:

1. Observation on December 9, 2024, at 11:52 a.m., revealed a residential type of range without a lock-out switch/device, was in the OT department.
Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed cooking equipment deficiency.

Based on documentation review and interview, it was determined the facility failed to perform the required inspections of the automatic fire alarm system in two instances, affecting the entire facility.

Findings Include:

1. Review of documentation on December 10, 2024, at 10:00 a.m., revealed the facility could not provide documentation for the following required testing of the automatic fire alarm system, to be performed within the past twelve months:

a) annual functional test of the automatic fire alarm system;
b) semi-annual visual inspection of the automatic fire alarm system.
Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the facility failed to provide documentation for the fire alarm system testing, at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting six of eleven smoke compartments.

Findings include:

1. Observation on December 9, 2024, revealed the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system in the following locations:

a) 10:14 a.m., there were multiple unsealed conduit penetrations in the ceiling of electrical closet number seven in acute care;
b) 10:30 a.m., there were unsealed dryer vent pipes in the ceiling of the personal laundry;
c) 10:41 a.m., there were multiple unsealed pipe penetrations in the ceiling of the MDF room;
d) 10:50 a.m., there was an unsealed penetration in the ceiling of the café above the refrigerator;
e) 11:24 a.m., there were unsealed exhaust vent pipes in the ceiling of the lab above the chemistry analyzers;
f) 11:25 a.m., there was an unsealed data wire in the ceiling of the lab in the plenix area;
g) 12:45 p.m., there were misaligned ceiling tiles in the cardiology nurse station.

Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.

2. Observation on December 9, 2024, at 1:00 p.m., revealed the facility failed to maintain storage below the eighteen-inch horizontal sprinkler plane in the storage room located in the aerobics area of the wellness center.

Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the storage interfered with automatic sprinkler system coverage.

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in three instances, affecting three of eleven smoke compartments.

Findings include:

1. Observation on December 9, 2024, revealed the following portable fire extinguisher deficiencies:

a) 10:40 a.m., there was an unsecured portable fire extinguisher in the MDF room;
b) 10:56 a.m., access to the portable fire extinguisher at the outside exit door by the receiving room was blocked by miscellaneous storage;
c) 12:33 p.m., there was an unsecured portable fire extinguisher in the MRI equipment room.


Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the emergency generator enclosure as a non-storage area, in one instance affecting one of 11 smoke compartments. Maintenance shall be in accordance with NFPA 110, 7.2.1.2

Findings include:

1. Observation on December 9, 2024, at 11:08 a.m., revealed the emergency generator room was being used to store miscellaneous items unrelated to the maintenance of the emergency generator.

Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed emergency generator room deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly testing in one instance, affecting the entire facility.

Findings include:

2. Review of documentation. December 10, 2024, at 10:00 a.m., revealed the facility could not provide monthly conductance test documentation for the emergency generator batteries for September, October, and November of 2024.


Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the missing emergency generator testing documentation.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly testing in one instance, affecting the entire facility.

Findings include:

1. Review of documentation. December 10, 2024, at 10:00 a.m., revealed the facility could not provide monthly conductance test documentation for the emergency generator batteries for September, October, and November of 2024.


Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the missing emergency generator testing documentation.

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in one instance, affecting one of eleven smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on December 9, 2024, at 11:58 a.m., revealed access to the electrical panels in the I Care Lounge storage room was blocked by miscellaneous storage items.


Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed electrical equipment deficiency.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eleven smoke compartments.

Findings include:

1. Observation on December 9, 2024, at 10:23 a.m., revealed there was a power strip plugged into an extension cord in electrical closet number six.

Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed electrical wiring systems deficiency.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage requirements in one instance, affecting one of eleven smoke compartments

Findings include:

1. Observation on December 9, 2024, at 10:33 a.m., revealed there was an unsecured oxygen cylinder in the LTC gym.


Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed medical gas storage deficiency.