HospitalInspections.org

Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the door frame in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 9 residents, visitors and staff in 1 of 6 smoke zones. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Observation and interview on 2/12/25 at 1:54 p.m., revealed the smoke doors number 924 failed to close and latch properly into their door frame.

2. Observation and interview on 2/12/25 at 1:55 p.m.,revealed the Med/Surgery smoke doors near the IT room failed to close and latch properly into their door frame.

3. Observation and interview on 2/12/25 at 2:11 p.m.,revealed the Cafeteria doors were held open with kick-down devices.

The Facilities Supervisor verified these findings during the survey process.

Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This deficient practice affects approximately 9 residents, staff, and visitors in 1 of 6 smoke zones. This facility has a capacity of 25 and a census of 3.

Findings include:

Observation and interview on 2/12/25 at 1:20 p.m.,revealed a two inch water pipe penetration through the smoke barrier wall above the doors to the Main Electric Gear Room.

The Facilities Supervisor verified these findings during 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 25 and a census of 3.

Findings include:

Observation and interview on 2/12/25 at 1:39 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 Environmental Services verified this observation at the time of the survey process.