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Based on observation and staff interview, the facility did not properly maintain enclose stairways used for exits and smoke proof enclosures in accordance with NFPA 101 (2012), Life Safety Code, section 7.1.3.2.1. These deficient findings could an isolated impact on the residents within the facility.

Findings include:

On On 08/13/2025 at 11:09am, it was revealed by observation that storage materials had been placed in the emergency exit vestibule in the emergency exit in told hospital south stairwell.

Based on observation and staff interview, the facility failed to maintain stairwell arrangement and markings per NFPA 101 (2012 edition), Life Safety Code, section 7.7.3.4. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 08/13/2025 at 11:59am, it was revealed by observation that an emergency exit egress gate must be placed in the stairwell leading to the main boiler room to prevent emergency egress beyond the low level exit.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On On 08/13/2025 at the following times, it was revealed by observation that listed storage rooms were missing and/or did not have a self-closing device;

1) At 11:06am on 2nd floor, storage room 222
2) At 12:01pm on Lower Level, storage room G8
3) At 12:11pm on Main level, clean storage room off Care Ctr.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/13/2025 at 10:59am, it was revealed by observation that the residential stove located on 2nd floor kitchen was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could an isolated impact on the residents within the facility.

Findings include:

On 08/13/2025 at 11:46am, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in the pharmacy office.

Based on observation and staff interview, the facility failed to maintain the automatic fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), the Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 5.4.1.4, and 5.4.1.4.2. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/13/2025 at 11:48am, it was revealed by observation that there were unsecured fire sprinkler heads that were not protected from being damaged, stored loosely within the spare sprinkler head boxes located by the fire sprinkler riser.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to secure electrical panels per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.3.2.2.1.3 and failed to maintain the Gas and Utility System per NFPA 101 (2012 edition), Life Safety Code section 9.2.2 and NFPA 54 (2012 edition), National Fuel Gas Code, sections 9.2.2 and 10.3.2.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/13/2025 at following times, it was revealed by observation that the electrical panels in the following areas were unlocked;

1) At 11:00am - electrical panel located in 2nd floor kitchen area was not locked.
2) At 11:08am - electrical panel located by Apartment #8 was not locked.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to secure the laundry chute door per NFPA 101 (2012 edition), Life Safety Code section 19.5.4.1. These deficient findings could have a widespread impact on the residents within the facility.

On 08/13/2025 at 12:18pm, it was revealed by observation that the laundry chute did not have a self closing door located on lower level. This device is required to close laundry chute in the event of a fire at bottom of chute.

On 08/13/2025 at 12:22pm, it was revealed by observation that the laundry chute did not have the required automatic extinguishing protection in accordance per NFPA 101 (2012 edition), Life Safety Code section 9.7.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On On 08/13/2025 at following times, it was revealed by observation that the following fire doors and/or fire door frames were missing and/or had painted over door rating tags.

1) At 11:05am Fire doors leading to 2nd floor - Painted door tags
2) At 11:07am Fire doors by apartment #5 - missing tags on door frames
2) At 11:19am Fire doors off Operating Room - missing tags on door frame

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to provide a battery-operated light in the generator room per NFPA 101 (2012 edition), Life Safety Code, section 7.9.2.3 and NFPA 110 Section 7.3. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/13/2025 @ 1020, it was revealed by observation that the Emergency Generator Room is missing the required battery-operated emergency light and/or light testing documentation.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.