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Based on observation and staff interview, the facility failed to maintain smoke resistant ceiling in a manner that would retard the spread of smoke to adjacent areas in the event of fire. Findings:

1. During a tour of the facility on 08/07/2024, the following observation was made:

a. The ceiling of the inside mechanical room (maintenance cut through) containing gas-fired boilers and/or gas-fired water heaters, was noted to have unsealed penetrations around vent pipe and gas lines exposing the wood attic space to the hazardous areas.

2. The Plant operations supervisor was present during the entire tour of the facility on 08/07/2024 and acknowledged the unsealed penetration.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings:

1. The facility records were reviewed on 08/07/2024. The most recent annual sprinkler inspection document was dated 09/11/2023.

A quarterly sprinkler inspection should have been performed in the fourth quarter of 2023 and the first and second quarter of 2024.

2. The Plant Operations Supervisor and the CEO stated at the exit they were not aware of the quarterly sprinkler inspection.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located in 1 of 3 smoke compartments. Findings:

1. A tour of the facility was conducted on 08/07/2024 and the following observation was made:

a. The Emergency Room #1 had a roller latch to keep the door closed.

2. The Plant Operations supervisor was present during the tour of the facility and acknowledged the roller latch on the door of ER #1.


Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation.

Based on observations and staff interview, the facility failed to maintain smoke barrier doors on 1 of 3 halls to close properly to resist the passage of smoke. Findings:

1. The smoke barrier doors between the ER and the lab area were test on 08/07/2024. These set of doors did not properly close and seal to resist the passage of smoke.

2. The Plant Operations Supervisor was present during the testing of the smoke doors and he stated he would get the doors fixed.

Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings

1. The facility records were reviewed on 08/07/2024 and no documentation was found to show the facility had conducted routine corridor door inspections.

2. The Plant Operations Supervisor was interviewed during the record review and he stated they do routine inspections on all doors, but they did not document the inspections.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Based on record review and staff interview, the facility failed to conduct weekly generator inspections and testing of the generator battery as required by NFPA 99. In the event of an electrical outage, the facility could not be assured the generator would function properly. Findings

1. The facility's records were reviewed on 08/07/2024. No documentation was found to show the facility had performed the weekly generator inspection and battery electrolyte testing for the past year.

2. The Plant Operations Supervisor was interviewed during the paper review on 08/07/2024 and he stated they have not been documenting the weekly inspection.