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Based on observation and interview, the facility failed to provide unobstructed egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.1.5.3), 2012 Edition. This deficient practice affects 1 staff or visitor in 1 of 6 smoke zones. This facility has a capacity of 25 and a census of three.

Findings include:

Observation and interview on 09/02/25 at 11:01 a.m., revealed the door to the Laundry Office contained a slide bolt lock. This lock would require a sliding manipulation in order to egress from the Laundry Office if the slide bolt was locked. Environmental Services Director verified this observation at the time of the survey process.

Based on observations and interviews, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. The facility had a capacity of 25 patients and a census of three at the time of the survey.

Findings include:

1. Observation and interview on 09/02/25 at 10:10 a.m., revealed the door to Maintenance Shop 002 failed to close and positively latch within the door frame, it appeared to be dragging on the concrete floor.

2. Observation and interview on 09/02/25 at 10:55 a.m. revealed the two Kitchen doors would not latch closed properly when tested; this appeared to be caused by the airflow in the kitchen.

The Environmental Services Director confirmed this observation at the time of the survey process.

Based on record review and staff interview, the facility failed to inspect and service the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The facility has a capacity of 25 with a census of three patients

Findings include:

Record review and staff interview on 09/02/25 at 10:14 a.m., revealed no available documentation of semi-annual inspections for the kitchen hood and duct system for May 2025. The last one completed was dated 11/21/24. The facility has been undergoing renovations and additions for approximately the last 6+ months. At the time of the survey, Feld Fire was on site conducting a semi-annual inspection. The Environmental Services Director confirmed this observation at the time of the survey.

Based on record review and interview, the facility failed to test the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5), 2010 Edition. This facility has a capacity of 25 and a census of three.

Findings include:

Record review and staff interview on 09/02/25 at 10:00 a.m., revealed no available documentation for the semi-annual inspection of the fire alarm system for May 2025. The last one completed was dated 11/26/24. The facility has been undergoing renovations and additions for approximately the last 6+ months. At the time of the survey, Feld Fire was on site conducting a semi-annual inspection. The Environmental Services Director confirmed this observation at the time of the survey.

Based on observation 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-5.4.1.4 and Section-5.4.1.4.1), 2011 Edition. This facility has a capacity of 25 and a census of three.

Findings include:

Observation and interview on 09/03/25 11:13 a.m., revealed a missing escutcheon ring in Shower Room 600A located within the Lab. The Environmental Services Director verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This facility has a capacity of 25 and a census of three.

Findings include:

Record review and interview on 09/03/25 at 10:46 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure. The CEO and Environmental Services Director verified this observation.

Based on observations and interview, the facility is not ensuring resident room doors, office doors, and other ancillary area doors to the corridor resist the passage of smoke in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.6.3.1. This deficient practice would not prevent the spread of smoke. This facility has a capacity of 25 with a census of five.

Findings include:

1. Observation and interview on 09/02/25 at 11:01 a.m., revealed the the door to the Laundry would not latch properly; the strike plate had been removed from the door frame.

2. Observation and interview on 09/02/25 at 11:00 a.m., revealed the Purchasing & Receiving Department door 0222 had a kick-down hold-open device on it.

The Environmental Services Director confirmed these observations during the survey process.

Based on record review and interview, the facility failed to document testing of hospital-grade electrical receptacles in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.4.1.1), 2012 Edition. This facility has a capacity of 25 and a census of three.

Findings include:

Record review and interview on 09/02/25 at 9:42 a.m., revealed the facility was unable to provide documentation for replacement, repair or modification of the hospital grade receptacles. The Environmental Services Director verified this observation at the time of the survey process.