HospitalInspections.org

Based on record review and interview, the facility failed to conduct biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5.3.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.

Findings include:

Record review and interview on 12/18/25 at 10:11 a.m., revealed during the interview that above facility had a sensitivity test in 2022. Facility should have had a sensitivity test in 2024 but had no record of a sensitivity test. Maintenance Director verified this finding during the process of interview.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.1.1.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.

Findings include:

Record review and interview on 12/18/25 at 10:21 a.m., revealed the facility failed to conduct quarterly testing of the sprinkler system for the 2nd, 3rd and 4th quarter of 2024 and 2025. During interview the facility had an annual inspection on 07/28/25 done by the sprinkler company. Company stated they only do two inspections a year for the hosptial. The Director of Maintanence verified this observation at the time of the survey process and has contacted Midwestern to do all 4 inspections to be done every 3 monthes.