HospitalInspections.org

National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition

4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

7.2.1.8 Self Closing Devices
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually, and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

Based on observation and interview, the facility failed to ensure doors with self-closing devices were held open with a release device designed to release upon loss of power.

Findings Include:

On 07/01/2025 at 1:34 PM, the central supply self-closing egress door had a hold open device not connected to the fire alarm system.

On 07/01/2025 at 1:34 PM, the central supply self-closing corridor door was held open with a hold open device not connected to the fire alarm system.

On 07/01/2025, the Administrator was present at each discovery.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

Article 406.6 Receptacle faceplates (Cover plates).
Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

On 07/01/2025 at 2:04 PM, in Room 100, the receptacle at the head of Bed 1 was missing its cover, exposing the wiring.

On 07/01/25 at 2:04 PM, the Administrator confirmed the missing receptacle cover.

Based on observation and interview, the facility failed to conduct fire drills once per shift, per quarter in 2025.

Findings include:

On 07/01/2025, the facility lacked documented evidence of a fire drill conducted during the second quarter day shift (6:00 AM to 6:00 PM) and the second quarter evening shift (6:00 PM to 6:00 PM).

On 07/01/2025 at 11:34 AM, the Administrator confirmed the missing fire drills.

Based on document review and interview, the facility failed to provide documented evidence smoke and fire door assemblies were inspected and tested not less than annually.

Findings include:

On 07/01/2025, the facility's records contain documentation fire door assemblies had been inspected and tested on 05/07/2024; however, lacked documented evidence of being inspected in May 2025.

On 07/01/2025, the Administrator confirmed more than one year had passed since the assemblies had been inspected and tested.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

210.8 Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
(A)(7) Sinks - located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

Based on observation and interview, the facility failed to install ground fault circuit interrupters (GFCI) in areas less than six feet from a sink edge.

Findings include:

On 07/01/202, the following receptacles were not GFCI receptacles as required:

- at 1:56 PM, in the isolation cart room, a duplex receptacle was 31 inches from the sink edge; however, the receptacle was not the required GFCI.
- at 2:11 PM, in the specialty outpatient room, a duplex receptacle was 41 inches from the sink edge; however, the receptacle was not the required GFCI.

On 07/01/2025, the Administrator confirmed the measurements and reported the breakers were not GFCI.

Based on document review and interview, the facility failed inspect its essential electrical system (EES) weekly and to test its EES under load 12 times a year.

Findings include:

On 07/01/2025, documentation of the following monthly load tests were not available:

04/23/2025 through 07/01/2025

On 07/01/2025, documentation of the following weekly EES inspections was not available:

03/03/2024 through 03/09/2024
03/11/2024 through 03/17/2024
03/19/2024 through 03/25/2024
05/25/2025 through 05/31/2025
06/01/2025 through 06/07/2025
06/08/2025 through 06/14/2025
06/15/2025 through 06/21/2025
06/22/2025 through 06/28/2025

On 07/01/2025, the Administrator confirmed the missing EES load tests and inspections.