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Based on observation, the facility failed to ensure that the fire proofing applied to the structural steel beams supporting the second level is maintained to achieve the required fire protection in accordance with NFPA 101, Life Safety Code, 2012 edition, Section 19.1.6.

Finding:

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following:

1. The fireproofing on the steel beam in Room 153 was scraped off in many locations. Please ensure that all fireproofing is intact on all required applications.

The surveyor confirmed this finding with the Maintenance Tech at the time of the observation during the facility tour.

Based on observations the Hospital failed to comply with the National Fire Protection Association Life Safety Code, 2012 Edition. Interior nonbearing walls required to have a minimum 2 hour fire resistance rating are permitted to be fire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided they are not used as shaft enclosures. 19.1.6.4, 19.1.6.5

Findings:

During a survey on 08/19/2025 during the hours of 11:00 AM and 4:00 PM, a surveyor with the Maintenance Tech present observed the following:

1. In Room 153 a metal pipe was penetrating the 2-hour fire-barrier wall with no fire-stopping present.

2. In Room 189 a metal pipe was penetrating the 2-hour fire-barrier wall with no fire-stopping present.

3. In Room 150 there was a 1 1/4 inch medical gas pipe penetration the 2-hour fire-barrier with no fire-stopping present.

These findings were confirmed by the surveyor and Maintenance Tech at the time of the facility tour.

Based on observations, the facility failed to ensure that doors at the means of egress meet the requirements of NFPA 101 life safety code 2012 edition sections 7.2.1.5.3 and 7.2.1.6.2 under requirements for door locks, latches, and alarm devices.
Findings:

On 08/19/2025 between 11:00 AM & 4 PM, a surveyor, with the Maintenance Tech present, observed the following:
1. The cross corridor doors that are part of a smoke barrier have top and bottom latching devices but the bottom latches do not latch as there is no striker plate in the floor or fire pins present.
2. The cross corridor egress exit door near patient room 103 has a keypad with no access code attached and no delayed egress for the door.
3. The same cross corridor door near patient room 103 going into the hospital has a turn dial that unlocks the door for 15 minutes but does not allow the door to latch securely for that time frame nor does it have delayed egress for that door.
The surveyor confirmed these findings with the Maintenance Tech at the time of observation.









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Based on observation, the facility failed to ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of required manual fire alarm system, and local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed; and loss of power per the requirements of NFPA 101, Life Safety Code, 2012 edition, Section 19.2.2.2.7.

Findings:

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following:

1. The 45 minute fire rated door to the bathroom in the Doctor's Lounge was not equipped with a self-closing device. The door shall self-close and positively latch as it's part of a 1-hour fire rated wall assembly and it is a fire rated door.

2. Rooms #38 and #190 have door closers that are not connected to the door, preventing them from self-closing and latching as designed.

The surveyor confirmed these findings with the Maintenance Tech at the time of the observation during the facility tour.

Based on observation, the facility failed to ensure that exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with survey and and certification letter 05-38.


On 08/18/2025, between 11:00 AM and 4:00 PM, a surveyor, with a Maintenance Tech present, observed the following:

1. The SNF Unit (Station 2) does not exit onto a level surface and does not lead back to a public way.

The surveyor confirmed these findings with the Maintenance Tech at the time of observation.

Based on observations and interviews with the Maintenance Tech, the facility failed to maintain and install the illuminated exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition sections 7.10.1.9, 7.10.5.2.1, and 19.2.10.

Findings include:

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following:

1. There is not illuminated exit signage identifying the exit pathway from the vestibule into Zone 6 by the cross corridor doors.

2. The illuminated exit sign by Patient Room 103 did not remain illuminated when the test button was pressed.

The surveyor confirmed these findings with the Maintenance Tech at the time of the observation during the facility tour.

Based on observations the Hospital failed to comply with the National Fire Protection Association Life Safety Code, 2012 Edition. Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2

Findings:

During a survey on 08/19/2025 during the hours of 11:00 AM and 4:00 PM, a surveyor with the Maintenance Tech present observed the following:

1. In the nurse break room (above the ceiling) there is exposed foam board insulation that does not have the required thermal barrier/covering per Title 25 section 2447-B of the state statue.

This finding was confirmed by the surveyor and Maintenance Tech at the time of the facility tour.

Based on observation and interview, the long-term care facility failed to install the water-based fire protection system throughout the premises in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Section 8.6.3.4.1 as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.5.

Finding:

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following:

1. Two sprinkler heads are installed less approximately 3-4 feet apart by Patient Room 103. The minimum spacing for pendant sprinkler heads without obstructions between them is 6 feet.

The surveyors acknowledged this finding with the Maintenance Tech at the time of the observation during the facility tour.

Based on observation during the facility tour the facility failed to install the portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers 2010 edition, Section 6.1.3.8.1 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 9.7.4.1., and 19.3.5.12.

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following during the facility tour.

Findings:

1. Fire extinguishers having a gross weight not exceeding 40 lb shall be installed so that the top of the fire extinguisher is not more than 5 ft above the floor. The fire extinguisher located in the nurses' station across from ICU is mounted on the wall approximately 5' 4 ¼" off the finished floor to the top of the extinguisher.

This finding was confirmed by this surveyor and the Maintenance Tech at the time of the observation during the facility tour..

Based on observation, the long-term care facility failed to maintain the corridor doors to resist the passage of smoke to and from the corridor by latching as referenced by NFPA 101, Life Safety Code 2012 edition, Section 19.3.6.3

Findings:

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following:

1. Roller latches are installed on the patient room cabinets in the corridor. The cabinets were used for trash and combustible storage.
2. The dining room door to the corridor isn't equipped with latching hardware. The corridor doors shall positively latch.
3. Room 190 across from the Nurse's station shall self close and latch. The door is not equipped with a closing device.
4. Room 38 across from the Nurse's station shall self close and latch. The door is not equipped with a closing device.
5. Zone 1 Oxygen storage room didn't latch.


The surveyor confirmed these findings with the Maintenance Tech at the time of the observation during the facility tour.




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Based on observation, the long-term care facility failed to maintain the corridor doors to resist the passage of smoke to and from the corridor by latching as referenced by NFPA 101, Life Safety Code 2012 edition, Section 19.3.6.3

Findings:

On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following:

1. Room 116 does not latch when closed. This was attempted x 4 times unsuccessfully.

The surveyor confirmed this finding with the Maintenance Tech ad the time of observation during the facility tour.

Based on observations and document review, the facility failed to ensure that the generator had proper maintenance records and was being exercised in accordance with the auxiliary generator power per NFPA 110 Section 8.4.9
Finding:
Based on document review and interview on 08/19/2025 between the hours of 11:00 AM and 4:00 PM. surveyors 39983 and 51673 accompanied by the Plant Engineer did observe the following:
1. The generator records for the EES indicate that the generator has not been tested for the required 4 continuous hours since October 2020. This requirement applies to all generator types if they supply a Level 1 EPSS. The Plant Engineer stated "due to a change of staff and reorganization of facility preventative maintenance schedules, this inspection was missed"
The surveyor confirmed this observation with the Plant Engineer at the time of the document review.