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Based on record review and staff interview it was determined the facility failed to ensure all essential mechanical and electrical equipment followed manufacturer-recommended maintenance activities and schedules. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.


Findings include:

Record review on 04/14/25 at approximately 2:07 p.m., revealed no documentation available for review during survey to show that all essential mechanical and electrical equipment was listed in an inventory, which includes a record of maintenance activities.

Record review on 04/14/25 at approximately 2:15 p.m., revealed no documentation available for review during survey to show that preventative maintenance for all essential mechanical and electrical equipment followed manufacturer's recommendations or an approved alternate equipment maintenance (AEM) program.

Interview on 04/15/25 at approximately 2:16 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on record review and staff interview it was determined the facility failed to ensure that appropriate air relationships, temperature, and humidity were maintained in patient care areas. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.


Findings include:

Record review on 04/14/25 at approximately 3:18 p.m., revealed no documentation available for review during survey to show that all patient care areas were being monitored for appropriate temperature, humidity, or air relationships (positive/negative).

Interview on 04/14/25 at approximately 3:26 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation, record review, and staff interview it was determined the facility failed to comply with the Health Care Occupancy chapter requirements of NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.


Findings include:

In reference to Federal Life Safety Code (FLSC) citation K 271, the facility failed to ensure that exit discharge was properly maintained.

In reference to FLSC citation K 321, the facility failed to ensure that hazardous areas were properly protected.

In reference to FLSC citation K 324, the facility failed to ensure that cooking equipment was properly protected.

In reference to FLSC citation K 353, the facility failed to ensure that the sprinkler system was properly tested and maintained.

In reference to FLSC citation K 372, the facility failed to ensure that fire/smoke barriers were maintained to the proper fire resistance rating.

In reference to FLSC citation K 511, the facility failed to ensure that electrical wiring and equipment was properly installed.

In reference to FLSC citation K 781 the facility failed to ensure that portable space heaters were properly used and tested.

In reference to FLSC citation K 918 the facility failed to ensure that the emergency generator was properly tested and maintained.

In reference to FLSC citation K 923 the facility failed to ensure that oxygen cylinders were properly stored and maintained.

Interview on 04/15/25 at approximately 2:08 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.