HospitalInspections.org

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

Findings include:

1. Observation on April 1, 2025, revealed the following automatic sprinkler system deficiencies:

a) 9:30 a.m., there was a gap greater than 1/8 inch in the ceiling tile surrounding a dryer exhaust line in Room 503, which could affect operation of the automatic sprinkler system;
b) 9:47 a.m., there was a gap greater than 1/8 inch in the ceiling tile surrounding a dryer exhaust line in Room 433.


Interview with the Director of Facilities and Facilities Coordinator on April 1, 2025, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, for one out of over 30 doors tested.

Findings include:

1. Observation on April 1, 2025, at 9:15 a.m., revealed the door to resident room 505 failed to latch when tested.

Interview with the Director of Facilities and Facilities Coordinator on April 1, 2025, at 2:00 p.m., confirmed the corridor door deficiency.