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AVERA GRANITE FALLS
Stairways and Smokeproof Enclosures
Tag No.: K0225
Based on obeservation and staff interview, the facility failed to maintain stairways and smokeproof enclosures per NFPA 101 (2012 edition), Life Safety Code, sections 7.2.1.1.1, and 7.2.1.15.8 . This deficient finding could have an isolated impact on residents within the facility.
Findings include:
On 03/12/2025 between 9:15 AM and 12:15 PM, it was revealed by observation that Basement Stairway Door #7 did not properly close and latch.
An interview with the Maintenance Director verified this deficient finding at the time of discovery. The Maintenance Director stated that a new door had already been ordered and they were waiting for it to arrive to replace the existing door that was not working properly.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Saftey Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.2.1.1.2(5). This deficient finding could have an isolated impact on residents within the facility.
Findings include:
On 03/12/2025 between 9:15 AM and 12:15 PM, it was revealed by observation that sprinkler heads in the 2nd floor staff kitchen were covered in lint and debris.
An interview with Maintenance Director verified this deficient finding at the time of discovery.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0374
Based on observation and staff interview, the facility failed to maintain smoke barrier doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.8, and 8.5.4.1. This deficient finding could have an isolated impact on the residents within the facility.
Findings include:
On 03/12/2025 between 9:15 AM and 12:15 PM, it was revealed by observation that Fire and Smoke Barrier Door 17 did not close completely when released from the magnetic hold-open device leaving a gap between the door leaves.
An interview with the Maintenance Director verified this deficient finding at the time of discovery.