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Based on observation and interview, the facility failed to provide self-closing devices on doors to hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.2.1/19.3.2.1.3 and 8.7. This deficient practice would prevent self-closing of doors when released to self-closing action, affecting all occupants in the First Floor CS Pharmacy. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observations on 1/29/25 at approximately 12:30 p.m., revealed the First Floor CS Pharmacy Housekeeping Room (1120) was not equipped with a self-closing device.


Maintenance Staff confirmed the observation at the time of discovery.

Based on observation and interview, the facility failed to assure that when the fire alarm is activated it automatically activates the required control functions and is provided with an alternate power supply in accordance with NFPA 72.

Findings include:

Observation on 1/29/25 at approximately 1:08 p.m., revealed the double doors located at "Hallway at Lab" and the door to "HEC" (AD101) did not automatically activate and close when the fire alarm system was tested.

This deficient practice was confirmed by Maintenance staff at time of survey.

Based on record review 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, 2011 edition, 5.2.1.1.2, by ensuring sprinklers were replaced if corroded. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This deficient practice affects all occupants in the first floor Kitchen area. This facility has a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review and observations on 1/29/25 at approximately 12:27 p.m., revealed five Sprinkler heads located in the First Floor Kitchen area were soiled with corrosion and a buildup of dust and debris.

This deficient practice was confirmed by Maintenance Staff at the survey.

Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 8.

Findings include:

Record review and interview on 1/29/25 at approximately 10:51 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not determine the extent and expected duration of the impairment. Nor did the policy address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure.

Maintenance Staff verified this observation at the time of the survey process.

Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The plan did not include information on all of the types of fire extinguishers and range hood and how to operate them. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review on 1/29/25, at approximately 10:55 a.m., revealed the plan does not address the use of K class fire extinguishers and how to use them or information about the range hood.

Maintenance Staff confirmed the findings at the time of exit.

Based on record review and interview, the facility failed to hold fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review on 1/29/25, at approximately 10:05 a.m., of the facility fire drill documentation conducted during 2024-2025 revealed the following:

1. No documentation of drills conducted on third shift of second quarter.

2. Documentation also revealed the following: two of four drills during first shift were conducted at 12:58 p.m. and 1:00 p.m. Two of four drill during second shift were conducted at 8:20 p.m. and 8:30 p.m., and two of four drills on second shift were conducted at 7:00 p.m. Two of four drills during third shift were conducted at 11:30 p.m. and 11:25 p.m.

Results of the record review were acknowledged by Maintenance Staff at the time of exit.

Based on observation, interview and record review, the facility did not store oxygen tanks in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.6.2.3 and 11.6.5, by ensuring tanks were adequately secured to prevent them from accidental damage or dislocation that may result in a missile-like action when the contents are rapidly discharged. This deficient practice occurred in the Second Floor Medical Surgery oxygen storage room (M202B) and affected approximately 8 occupants. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation on 1/29/25, at approximately 12:49 p.m., revealed the Second Floor Medical Surgery oxygen storage room (M202B) had four cylinders not properly secured.

This deficient practice was confirmed by Maintenance Staff at the time of discovery.