HospitalInspections.org

Based on observation, interview, and testing, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2. 7), 2012 Edition. This deficient practice affects approximately 2 residents, staff, and visitors. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation, interview, and testing on 09/23/25 at 1:00 p.m., revealed the 90 minute fire rated door to room #1609 failed to fully self-close and positively latch within the door frame when tested. The top of the door was bowed out approximately 1/2 inch. The Director of Ancillary Services verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide fire alarm notification in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.3.5), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the enclosed courtyard. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 09/23/25 at 12:22 p.m., revealed the Enclosed Courtyard did not contain an audible and visible notification device for the fire alarm system being activated. The Director of Ancillary Services verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.1.1.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 09/23/25 at 12:53 p.m., revealed that 4 standard response sprinkler heads in the Kitchen contained excessive dirt and lint on the sprinkler bulb, arms and diffuser. The sprinklers were located on the ceiling around the hood system. The Director of Ancillary Services verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-5.6.5.6), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 09/23/25 at 12:31 p.m., revealed the emergency generator for the facility was located outdoors. The facility failed to provide a remote manual stop station located outside the generator housing a safe distance away from the generator. The Director of Ancillary Services verified this observation at the time of the survey process.