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Based on observation and interview, the facility failed to ensure hazardous areas are protected by a fire barrier doors that are self-closing or automatic-closing in accordance with 2012 NFPA 101 8.7.1.1 and 8.7.1.3. This deficient practice could affect 10 occupants in the event of a fire or smoke event.

Findings Include:

1. On November 13, 2024 at approximately 11:10 AM observation revealed the linen storage room door across from the doctors lounge does not close and positively latch.

2. On November 13, 2024 at approximately 11:15 AM observation revealed the old nuclear medicine room has been converted into a storage space containing combustible cardboard boxes. The door to the new storage space is not self closing or automatic closing.

3. On November 13, 2024 at approximately 11:30 AM observation revealed the door to the soiled utility prewash space is not on a self closure or automatic closing device.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:

On November 13, at approximately 2:45 PM record review revealed the facility annual swinging fire door documentation does not have inspection and test information for all the swinging type fire doors in the facility. The inspection form only denotes the cross corridor fire doors. This may lead to the other fire doors in the facility failing to function as designed when needed during a fire.

These findings were confirmed through interview with the maintenance director at the time of record review.

Based on observation and interview, the facility failed to ensure portable space heating devices are prohibited, unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 19.7.8. This deficient practice could affect 8 occupants in the event of space heater related fire.

Findings Include:

On November 13, 2024 at approximately 11:50 AM observation revealed a portable space heater running on the file cabinet shelf in the physical therapy space. The space heater could not be verified to not exceed 212 degrees Fahrenheit.

These findings were confirmed thorough interview with the maintenance director at the time of observation.

Based on record review and interview, the facility failed to ensure the gas and vacuum systems are inspected and tests and records are maintained as required by 5.1.14.2.3, 5.1.15, 5.2.14, 5.3.13 and 5.3.13.4 of NFPA 99. This deficient practice could affect all occupants in the event of a medgas and/or med vacuum failure.

Findings Include:

On November 13, 2024 at approximately 2:00 PM record review revealed the facility cannot produce documentation to verify med vacuum is inspected at least annually.

On November 13, 2024 at approximately 2:00 PM record review revealed the facility cannot produce documentation to verify the internal oxygen facility components are inspected at least annually.

These findings were confirmed through interview with the maintenance director at the time of record review.

Based on observation and interview the facility failed to provide electrical safety measures in accordance with NFPA 99. 6.4.4.1.2.1. This deficient practice could effect 20 occupants in the event circuit breakers are accessed and shut off to resident rooms.

1. On November 13, 2024 at approximately 11:40 AM observation revealed the electrical circuit breaker box across from the Room 154 is unsecured. This will potentially allow the breakers to be inadvertently shut off terminating the power to patient rooms and other vital equipment.

2. On November 13, 2024 at approximately 12:00 PM observation revealed the electrical circuit breaker box next to Emergency Room 2 labeled panel F and Panel EH are unsecured. This will potentially allow the breakers to be inadvertently shut off terminating the power to patient rooms and other vital equipment.


These findings were confirmed through interview with the Maintenance director at the time of observation.

Based on observation and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect 10 occupants in the event of an oxygen related fire, oxygen cylinder damage or misuse.

Findings Include:

On November 13, 2024 at approximately 11:00 AM observation revealed oxygen cylinders in the oxygen cylinder storage closet next to room 154 are mixed and not segregated between full and empty cylinders. Full and empty cylinders were located together in the same location and not designated full and empty by dedicated signage.

These findings were confirmed through interview with the maintenance director at the time of observation.