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Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This facility has a capacity of 25 and a census of 2.

Finding include:

Observation and interview on 7/7/25, at approximately 11:05 a.m., revealed the facility failed to maintain the ceiling in the IT Switch Gear Room. Three two inch penetrations were observed in the ceiling.

Maintenance Staff verified these observations at the time of the survey process.

Based on observation, interview and record review, the facility did not assure that all doors in a means of egress are limited to one locking device in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.2.2.2.6(2)/19.2.2.2.6(2). The doors allow access to a public way (a street or similar area open to the outside air and dedicated to public use). Visitors, staff and residents use these paths in the event of an emergency evacuation and this deficient practice affected all occupants in the Senior Life Solutions building.

Findings include:

Observation on 7/7/25, at approximately 12:44 p.m., revealed the following doors had two locking devices (deadbolt locks) on the doors:

1. West Exit Door.
2. East Exit Door.
3. North Exit Door.

Maintenance Staff confirmed the observations and findings at the times of discovery.

Based on observation and interview, the facility is not providing a corridor arranged with clear or unobstructed exit access to the convenient removal of non-ambulatory persons carried on stretchers in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.3.5. This deficient practice affects all residents, staff, and visitors that my need to be evacuated from the Old West Wing. This facility had a capacity of 25 with a census of 2 residents at the time of the survey.

Findings include:

Observation and interview on 7/7/25, at approximately 11:20 a.m., revealed an excess of storage in the Old West Wing Hallway that protruded into the corridor.

Maintenance Staff confirmed this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain exit doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the Senior Life Solutions Building.

Findings include:

Observation and interview on 7/7/25 at approximately 12:44 p.m., revealed the North, West, and East Exit Doors leading to the outside, in the Senior Life Solutions Building, did not swing in the direction of egress.

Maintenance Staff confirmed these findings at the time of discovery.

Based on observation and interview, the facility failed to maintain exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.10.5.1), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the North Ambulance Garage and the East Ambulance Garage. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 7/7/25 revealed the following:

1. At approximately 11:46 a.m., revealed the North Ambulance Garage did not have an Emergency Exit Sign.
2. At approximately 11:27 a.m., revealed the East Ambulance Garage did not have an Emergency Exit Sign.

Administrative Staff and Maintenance Staff confirmed the findings at the time of discovery.

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. This facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Observations on 7/7/25 revealed the following:

1. At approximately 11:29 a.m., revealed the South End West Storage Room was not equipped with a self-closing device.

2. At approximately 11:38 a.m., revealed the Medical Imaging Storage Room was equipped with a self-closing device that had been disconnected.

3. At approximately 12:21 p.m., revealed the E.V.S. Storage Room door was not equipped with a self-closing device.


Maintenance Staff confirmed the observation at the time of discovery.

Based on interview and record review, the facility failed to protect the range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2.1 by having them inspected and tested every six months. This facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Record review conducted on 7/7/25, at approximately 12:31 p.m., revealed this facility was unable to provide documentation for their semi-annual Hood Suppression System inspection.

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

Based on observation, 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 affected all staff and residents. This facility has a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Observation and interview on 7/7/25, revealed the following:

1. At approximately 11:47 a.m., revealed one soiled Sprinkler Head in E.R Exam Room 3.
2. At approximately 12:31 p.m., revealed the facility was unable to provide documentation for their most recent Sprinkler inspection.

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

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 all residents, staff, and visitors in the South End West Storage Room and the Accounting Records Storage Room. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 7/7/25 revealed the following:

1. At approximately 11:29 a.m., revealed the South End West Hall Storage Room had ceiling tiles missing.
2. At approximately 11:10 a.m., revealed the Accounting Records Room had ceiling tiles missing.

Maintenance Staff and Administrative Staff confirmed these findings at time of discovery.

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 fire plan also did not include information on the range hood and how to operate it. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 7/7/25 at approximately 10:36 a.m., of the Facilities Emergency Plan and Procedures revealed it did not address information about the range hood an how to operate it.

Administrative Staff and Maintenance Staff confirmed the findings at the time of exit.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation did not show the drills have been held as required, including varying conditions (such as timing). 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 2 residents at the time of the survey.

Findings include:

Record review on 7/7/25, at approximately 9:49 a.m., of the facility fire drill documentation conducted during 2024/2025 revealed the following:

1. Three of four second shift drills were conducted at 10:00 a.m., 9:30 a.m. and 9:26 a.m.

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