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Based on observation and interview, the facility failed to maintain the fire barrier in one of over three hazardous areas.

Findings include:

Observation on September 16, 2025, at 12:18 p.m., revealed the soiled utility room on the second floor was intentionally blocked from closing and self-latching by a waste can.

Interview with the maintenance supervisor on September 16, 2025, at 12:18 p.m., confirmed the door was intentionally blocked, preventing the self-closing door from closing and latching.

Based on observation and interview, the facility failed to maintain portable fire extinguishers in one of two kitchens.

Findings include:

Observation on September 16, 2025, at 10:27 a.m., revealed the first-floor coffee shop food cooking area lacked a portable Class K fire extinguisher.

Reference: NFPA 101 19.3.2.5 and NFPA 96 10.10

Interview with the maintenance supervisor on September 16, 2025, at 10:27 a.m., confirmed the Class K fire extinguisher was not present.

Based on observation and interview, the facility failed to maintain six of more than thirty electrical receptacles.

Findings include:

Observation on September 16, 2025, between 11:02 a.m. and 12:35 p.m., revealed the following electrical outlet deficiencies:
1. (11:02 a.m.) Laundry room had an unprotected receptacle located within six feet of a sink. The clothes washer was connected to a receptacle without ground fault circuit interrupter (GFCI) protection;
2. (11:24 a.m.) hand wash station located outside the operating room had a receptacle that was not GFCI-protected located within six feet of a water basin;
3. (11:30 a.m.) Nuclear med room had a hand sink with a receptacle that was not GFCI-protected located within six feet of a water basin;
4. (11:40 a.m.) Kitchen dirty side of dishwashing area had a receptacle that was not GFCI-protected located within six feet of a water basin;
5. (12:35 p.m.) Pharmacy had a hand sink with a receptacle that was not GFCI-protected located within six feet of a water basin.

Interview with the maintenance supervisor on September 16, 2025, at 12:35 p.m., confirmed the electrical outlet deficiencies.

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one diesel emergency generator.

Findings include:

Document review on September 16, 2025, at 10:37 a.m., revealed the annual vendor inspection found the jacket water heater outlet fitting was leaking coolant and needed replaced. The facility failed to provide documentation that the leak was fixed.

Interview with the facilities manager on September 16, 2025, at 10:37 a.m., confirmed the corrective documentation was unavailable at the time of the survey.