31 Reports
Inspection Report — Jun 30, 2026
Complaint Investigation
Date: Jun 30, 2026
Visit Reason
Investigation of a facility reported incident #3038488.
Findings
Eastport Memorial Nursing Home was found in compliance with 42 CFR Part 483, Subpart B requirements for Long Term Care Facilities on 06/30/26.
Report Facts
: 3038488
Inspection Report — May 5, 2026
Re-Inspection
Date: May 5, 2026
Visit Reason
This report documents an off-site desk review conducted on 5/5/26 as a follow-up to the Revisit survey completed on 4/9/26.
Findings
Eastport Memorial Nursing Home was determined to be in substantial compliance with 42 CFR 483, Subpart B, Requirements for Long Term Care Facilities.
Inspection Report — Apr 8, 2026
Annual Inspection
Date: Apr 8, 2026
Visit Reason
Annual Long Term Care Survey conducted off-site from 4/7/26 through 4/9/26 to assess compliance with federal regulations.
Findings
Eastport Memorial Nursing Home was found not in substantial compliance with 42 CFR 483 requirements. Deficiencies were identified in maintaining a safe and homelike environment, implementing an antibiotic stewardship program, ensuring influenza and pneumococcal immunizations, and COVID-19 immunization policies and documentation.
Deficiencies (4)
F0584: The facility failed to maintain the building in a sanitary and homelike condition, evidenced by unrepaired flooring hazards creating an uncleanable surface and non-homelike environment.
F0881: The facility failed to implement an antibiotic stewardship program that includes protocols and a system to monitor antibiotic use, potentially affecting all residents receiving antibiotics.
F0883: The facility failed to ensure residents were offered and received influenza and pneumococcal immunizations according to CDC recommendations, affecting all residents not up to date on these vaccines.
F0887: The facility failed to provide adequate education, screening, documentation, and vaccine administration for COVID-19 immunizations to staff and residents, potentially affecting all residents and staff.
Report Facts
: 1E070B-H2
: 2904
Inspection Report — Apr 7, 2026
Plan of Correction
Date: Apr 7, 2026
Visit Reason
This document is the facility's plan of correction for the survey completed on 04/09/2026 addressing deficiencies related to safe environment, antibiotic stewardship program, immunizations, and COVID-19 immunization.
Findings
This is the facility's plan of correction for the survey of 04/09/2026. The plan addresses deficiencies cited under rules F0584, F0881, F0883, F0887 concerning safe environment, antibiotic stewardship, influenza and pneumococcal immunizations, and COVID-19 immunization.
Report Facts
: 1E070B-H2
: 2904
Inspection Report — Apr 7, 2026
Follow-Up
Date: Apr 7, 2026
Visit Reason
Off-site desk reviews were conducted for follow-up to the facility reported incident investigation #2711170 and complaint investigation #2714931 completed on 1/27/26.
Findings
The deficiencies cited at the 1/27/26 survey were corrected at the time of the off-site desk review on 4/7/26 and 4/9/26.
Report Facts
: 2711170
: 2714931
Inspection Report — Feb 9, 2026
Plan of Correction
Date: Feb 9, 2026
Visit Reason
Annual Long Term Care Survey and Recertification to assess compliance with 42 CFR Part 483 requirements.
Findings
This document is the facility's plan of correction for the survey completed on 2026-02-11, addressing deficiencies related to resident rights and baseline care plans.
Report Facts
: 1E070B-H1
: 205146
: Feb 11, 2026
: Mar 30, 2026
Inspection Report — Feb 9, 2026
Annual Inspection
Date: Feb 9, 2026
Visit Reason
The survey was conducted as part of the annual Long Term Care Survey Process for Federal Recertification.
Findings
The facility was found not in compliance with multiple federal requirements including resident dignity and respect, safe environment maintenance, PASARR coordination, baseline care planning, quality of care, nurse aide performance review, infection prevention and control, antibiotic stewardship, immunization protocols, COVID-19 vaccination, and staff training requirements.
Deficiencies (11)
F0550: The facility failed to ensure residents were treated with respect and dignity while providing care for 2 of 2 residents reviewed for dignity.
F0584: The facility failed to provide a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain the building in good repair.
F0644: The facility failed to coordinate assessments with PASARR program recommendations and ensure referrals for level II resident review for 2 of 3 sampled residents.
F0655: The facility failed to develop and implement baseline care plans within 48 hours that included instructions needed to provide minimum healthcare information for 2 of 4 sampled residents.
F0684: The facility failed to follow a physician's order for in-house physical therapy for 1 of 2 sampled residents reviewed for position and mobility.
F0730: The facility failed to complete an annual performance evaluation at least every 12 months for 1 of 5 sampled employees (CNA3).
F0880: The facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.
F0881: The facility failed to implement its Antibiotic Stewardship Program including antibiotic use protocols and monitoring for 2 of 2 months reviewed.
F0883: The facility failed to ensure residents were offered influenza and pneumococcal vaccinations in accordance with CDC recommendations for 4 of 5 residents reviewed.
F0887: The facility failed to offer the updated COVID-19 vaccine for 1 of 5 residents reviewed.
F0940: The facility failed to implement and maintain an effective training program by failing to ensure that 5 of 5 Certified Nursing Assistants completed required in-service trainings.
Report Facts
: 2026-02-09 to 2026-02-11
: Jul 20, 2020
: Dec 8, 2025
: Jun 2, 2025
: Jan 20, 2026
Inspection Report — Feb 9, 2026
Re-Inspection
Date: Feb 9, 2026
Visit Reason
This re-inspection was conducted to verify compliance with fire safety and corridor door regulations following previous deficiencies.
Findings
The facility failed to maintain means of egress free of obstructions and did not ensure corridor doors properly resist smoke passage and latch correctly, violating NFPA 101 Life Safety Code, 2012 edition.
Deficiencies (3)
K0211: Means of egress were obstructed by trash bins and portable hood pressure machines in corridors, violating NFPA 101 Life Safety Code, 2012 edition, section 7.1.10.1.
K0331: Interior wall and ceiling finishes did not meet NFPA 101 Life Safety Code, 2012 edition, sections 102 and 19.3.3.1, 19.3.3.2, due to exposed interior surfaces lacking required flame spread ratings.
K0363: Corridor doors failed to resist smoke passage and did not latch properly, violating NFPA 101 Life Safety Code, 2012 edition, section 19.3.6.3.1; doors to resident rooms 1 and 2 did not protect corridor openings from smoke and fire.
Report Facts
: 39983
Inspection Report — Feb 9, 2026
Date: Feb 9, 2026
Visit Reason
Federal Recertification Survey for Eastport Memorial Nursing Home.
Findings
Eastport Memorial Nursing Home is in substantial compliance with 42 Code of Federal Regulations Part 483.73 Requirement for Long Term Care Facilities Emergency Preparedness and the National Fire Protection Association 101 Life Safety Code 2012 Edition.
Inspection Report — Nov 12, 2025
Complaint Investigation
Date: Nov 12, 2025
Visit Reason
An unannounced visit was conducted to investigate complaint #2658292.
Findings
Eastport Memorial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Report Facts
: 2658292
Inspection Report — Aug 13, 2025
Follow-Up
Date: Aug 13, 2025
Visit Reason
Unannounced offsite desk review to follow up on deficiencies cited in complaint investigations #ME00052124 and #ME00052125.
Findings
Eastport Memorial Nursing Home was found to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities during the follow-up review.
Report Facts
: ME00052124
: ME00052125
Inspection Report — Jul 28, 2025
Follow-Up
Date: Jul 28, 2025
Visit Reason
This was an offsite desk review conducted for the purpose of follow-up to citations issued during a complaint survey dated 6/23/25.
Findings
There were no regulatory deficiencies identified as a result of the 7/28/25 revisit investigation.
Report Facts
: Jun 23, 2025
Inspection Report — Jun 23, 2025
Date: Jun 23, 2025
Visit Reason
Investigation of facility reported incidents #ME00051616 and #ME00051680 related to resident elopement and wandering.
Findings
The facility failed to provide adequate supervision and secure exits to prevent resident elopements, resulting in two incidents within a five-day period. The facility's Elopement and Wandering Policy was not fully effective, and staff failed to ensure door alarms were functioning properly.
Deficiencies (2)
F656: The facility failed to develop and implement a comprehensive person-centered care plan addressing measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs, as evidenced by two facility reported incidents of elopement within five days.
F689: The facility failed to ensure the resident environment remained free of accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents, as evidenced by a resident actively exit seeking and eloping multiple times due to unsecured exits and malfunctioning door alarms.
Report Facts
: 2
Inspection Report — Apr 30, 2025
Follow-Up
Date: Apr 30, 2025
Visit Reason
Off-site desk audit conducted to follow up on the 3/18/25 follow-up for the annual Long Term Care Survey Process for Federal Recertification dated 1/29/25.
Findings
Eastport Memorial Nursing Home was determined to be in substantial compliance with 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report — Mar 18, 2025
Follow-Up
Date: Mar 18, 2025
Visit Reason
This follow-up survey was conducted to assess the facility's compliance with previously cited deficiencies from the annual Long Term Care Survey dated 1/29/25.
Findings
The facility was found not in substantial compliance due to multiple deficiencies including unsanitary respiratory equipment, improper labeling and storage of drugs, and failure to implement effective quality assurance and performance improvement plans. The Plan of Correction for prior deficiencies was not fully implemented or effective as of the revisit date.
Deficiencies (3)
483.25(i): Respiratory equipment was not maintained in a sanitary manner, resulting in heavily soiled filters on oxygen concentrators for 2 of 3 residents observed.
483.45(g)(h)(1)(2): Drugs and biologicals were not properly labeled with open and expiration dates, including insulin pens and vials, risking use of expired medications.
483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i): The facility's quality assurance program failed to implement and sustain corrective actions for multiple prior deficiencies, including comprehensive assessments, care planning, quality of care, and safety hazards.
Report Facts
: Feb 14, 2025
: Mar 18, 2025
: Mar 6, 2025
: Mar 8, 2025
Inspection Report — Jan 28, 2025
Annual Inspection
Date: Jan 28, 2025
Visit Reason
The survey was conducted to complete the annual Long Term Care Survey Process for Federal Recertification. Deficiencies were identified related to resident assessments, care planning, activity professional qualifications, quality of care, accident hazards, respiratory care, medication storage, and infection control.
Findings
The facility was found not in substantial compliance with federal requirements. Deficiencies included failure to complete timely comprehensive and significant change assessments for a hospice resident, inadequate care planning for a resident with heart failure and atrial fibrillation, unqualified activity director, failure to follow provider orders for daily weights and pharmacist recommendations, inadequate supervision leading to an elopement, improper respiratory care and equipment sanitation, expired medication in storage, and incomplete water management program for Legionella prevention.
Deficiencies (9)
F636: The facility failed to complete an annual Comprehensive Minimum Data Set 3.0 assessment timely for 1 of 1 residents reviewed for hospice (Resident #23).
F637: The facility failed to complete a significant change in status Minimum Data Set 3.0 assessment within 14 days of a resident's admission to hospice services for 1 of 1 sampled residents (Resident #23).
F656: The facility failed to develop a care plan to address the physical needs of a resident with heart failure and atrial fibrillation, including monitoring and management of anticoagulant medication, for 1 of 5 residents reviewed.
F680: The facility failed to employ a qualified Activity Director who completed a State-approved program to manage resident-centered activities for all residents (24 residents).
F684: The facility failed to follow a doctor's order for daily weights for a resident with heart failure and failed to appropriately address a pharmacist recommendation regarding psychotropic medication for another resident.
F689: The facility failed to monitor an unlocked and/or non-alarmed door during a fire alarm, resulting in an avoidable elopement of a resident identified as an elopement risk (Resident #15).
F695: The facility failed to maintain a physician ordered oxygen setting on an air concentrator and failed to maintain respiratory equipment in a sanitary manner for 2 of 3 residents reviewed for respiratory care (Residents #20 and #8).
F761: The facility failed to remove an expired vial of Novolog insulin from medication storage, which was being used 16 days past expiration for Resident #9.
F880: The facility failed to fully develop and implement a water management program to prevent the growth and spread of Legionella and other waterborne pathogens, lacking testing protocols and monitoring procedures.
Report Facts
: 592
: 16
: 1.5
: 3
Inspection Report — Jan 28, 2025
Date: Jan 28, 2025
Visit Reason
Federal Recertification Survey for Eastport Memorial Nursing Home.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements including egress doors, exit signage, hazardous area enclosures, cooking facilities, sprinkler system installation and maintenance, corridor doors, fire drills, electrical systems, emergency power supply, and gas equipment storage.
Deficiencies (13)
K222: The facility failed to ensure doors at the means of egress met NFPA 101 life safety code 2012 edition 7.2.1.6.1 for delayed egress; a hallway exit door was locked against egress without proper signage or delayed egress system.
K293: The facility failed to maintain illuminated exit signage in accordance with NFPA 101 sections 7.10.1.9, 7.10.5.2.1, and 19.2.10; exit signs were installed too low and did not remain illuminated when tested.
K321: The facility failed to protect hazardous areas per NFPA 101 2012 edition by not having required fire barriers or automatic fire extinguishing systems separating hazardous areas from other spaces.
K324: The facility failed to protect cooking facilities in accordance with NFPA 96 and NFPA 101 by not inspecting the entire exhaust system for grease buildup and not properly marking cooking appliances on wheels.
K351: The facility failed to install the water-based fire protection sprinkler system in accordance with NFPA 13, 2010 edition, Section 6.2.9.7, as referenced by NFPA 101 2012 edition, Section 19.3.5.
K353: The facility failed to maintain the water-based fire protection system piping free of external loads per NFPA 25, 2011 edition, Section 5.2.2.2.
K363: The facility failed to maintain corridor doors that positively latch and close per NFPA 101 2012 edition Section 19.3.6.3.
K712: The facility failed to use a coded announcement during third shift fire drills between 21:00 and 06:00 per NFPA 101 2012 edition section 19.7.1.7.
K761: The facility failed to provide documentation that doors had been inspected by a trained employee and maintain written records of door inspections per NFPA 80 2010 edition Sections 5.2 and 5.2.3.
K914: The facility failed to ensure hospital-grade electrical receptacles at patient bed locations were tested at intervals not exceeding 12 months per NFPA 99 2012 edition Section 6.3.3.2.4.
K916: The facility failed to ensure the emergency power system annunciator was operational and scheduled for required testing per NFPA 99 2012 edition Section 6.4.1.1.17.
K918: The facility failed to maintain the emergency power generator and transfer switches per NFPA 110 2010 edition Sections 8.3.7 and 8.4.1, and NFPA 99 2012 edition Section 6.4.4.1.1.3.
K923: The facility failed to safeguard gas cylinder and container storage areas per NFPA 99 2012 edition Sections 5.1.3.3.2 and 5.1.3.3.3; combustible storage was within 5 feet of oxygen cylinders exceeding allowed limits.
Report Facts
: Jan 28, 2025
: 09:00 AM to 12:15 PM
: March 2025
: Mar 12, 2025
: March 5, 2025
: Feb 14, 2025
: Feb 17, 2025
: Jan 28, 2025
: Feb 13, 2025
: 14
: 336
Inspection Report — Nov 26, 2024
Follow-Up
Date: Nov 26, 2024
Visit Reason
Follow-up survey conducted offsite for complaint #ME00048995.
Findings
Eastport Memorial Nursing Home was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Report Facts
: ME00048995
Inspection Report — Apr 24, 2024
Complaint Investigation
Date: Apr 24, 2024
Visit Reason
An unannounced visit was conducted to investigate complaint #ME00046384.
Findings
Eastport Memorial Nursing Home was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Report Facts
: ME00046384
Inspection Report — Mar 26, 2024
Follow-Up
Date: Mar 26, 2024
Visit Reason
On 3/26/24, an on-site visit was conducted for the purpose of following up on the annual Long Term Care Survey Process for Federal Recertification and complaints #ME00043111, #ME00043604, and #ME00045481.
Findings
Eastport Memorial Nursing Home was determined to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Report Facts
: ME00043111
: ME00043604
: ME00045481
Inspection Report — Jan 11, 2024
Annual Inspection
Date: Jan 11, 2024
Visit Reason
The survey was conducted for the annual Long Term Care Survey Process for Federal Recertification and complaints.
Findings
The facility was found not in compliance with several federal requirements including notification of changes, safe environment, reporting of alleged violations, investigation of alleged violations, notice requirements before transfer/discharge, comprehensive assessments and timing, baseline care plan, treatment to prevent and heal pressure ulcers, infection prevention and control, resident records confidentiality, and trauma informed care. Corrective actions and monitoring plans were established with completion dates ranging from February to March 2024.
Deficiencies (20)
F580 Notification of Changes: The facility failed to ensure that the resident's physician was notified immediately of a significant change in the resident's medical condition for 1 of 2 residents reviewed.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 1 of 1 environmental tours.
F609 Reporting of Alleged Violations: The facility failed to report suspected abuse to the State Survey Agency in a timely manner after it was brought to their attention that a resident was abused physically.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate an allegation of suspected abuse for 1 of 1 abuse allegations investigated.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide a transfer notice to the resident and resident representative for 2 of 3 sampled residents reviewed for hospitalization.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to issue a written bed hold notice to the resident and/or resident representative for 2 of 3 sampled residents reviewed for hospitalization.
F636 Comprehensive Assessments & Timing: The facility failed to complete and submit all admission and discharge assessments for 3 residents reviewed.
F640 Encoding/Transmitting Resident Assessments: The facility failed to encode and transmit required resident assessments within the required timeframes for 1 of 1 closed records reviewed for hospitalization.
F645 PASARR Screening for MD & ID: The facility failed to ensure proper completion of PASRR for 1 resident reviewed.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement a comprehensive care plan that included all required elements for 2 of 3 newly admitted sampled residents.
F657 Care Plan Timing and Revision: The facility failed to update care plans timely to reflect residents' current needs related to oxygen and gastrointestinal bleeding for 2 of 14 sampled residents reviewed.
F684 Quality of Care: The facility failed to provide proper documentation and monitoring of changes in a resident's condition and communication with the physician for 1 of 1 closed records reviewed for death.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure physician orders and weekly wound assessments were completed for pressure ulcers for 3 of 5 residents reviewed.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure electrical outlet adapters were safe and maintained in 3 of 3 days of survey.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure proper use and maintenance of BiPap machines and oxygen concentrators for 1 resident reviewed.
F699 Trauma Informed Care: The facility failed to identify and address triggers causing re-traumatization for 1 of 1 sampled resident with PTSD diagnosis.
F710 Resident's Care Supervised by a Physician: The facility failed to ensure physician supervision and documentation of pressure ulcer care for 3 of 4 residents reviewed.
F842 Resident Records - Identifiable Information: The facility failed to maintain confidentiality of resident records and ensure proper documentation for 3 of 14 residents reviewed.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program including proper dressing change procedures and hand hygiene for 1 of 1 dressing change observation.
F881 Antibiotic Stewardship Program: The facility failed to notify the Medical Provider timely of a negative urinalysis result for 1 of 1 resident reviewed for antibiotic use.
Report Facts
: Feb 25, 2024
: Feb 6, 2024
: Jan 31, 2024
: Feb 2, 2024
Inspection Report — Jan 8, 2024
Annual Inspection
Date: Jan 8, 2024
Visit Reason
Annual Long Term Care Survey Process for Federal Recertification and complaints #ME00043111, #ME00043604, and #ME00045481.
Findings
The facility was found not in compliance with multiple regulatory requirements including failure to notify physicians timely, inadequate housekeeping and maintenance, failure to report and investigate abuse allegations, lack of proper transfer and bed hold notices, incomplete assessments and care plans, inadequate respiratory care, and infection control deficiencies.
Deficiencies (20)
F580: The facility failed to ensure the resident's physician was notified immediately of a significant change in the resident's medical condition for 1 of 2 residents reviewed.
F584: The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and sanitary condition, including peeling paint, gouged walls, unsecured door protectors, and dusty fans.
F609: The facility failed to report suspected abuse to the State Agency in a timely manner and failed to thoroughly investigate an allegation of suspected abuse for 1 resident.
F623: The facility failed to notify residents or their representatives in writing of transfer/discharge reasons and failed to provide timely transfer notices for 2 residents.
F625: The facility failed to provide written bed hold notices to residents or their representatives for 2 residents transferred to hospital.
F636: The facility failed to complete an Admission Comprehensive Minimum Data Set with Care Area Assessment in a timely manner for 1 resident.
F640: The facility failed to transmit electronically the Minimum Data Set assessments to the State database for 1 resident.
F645: The facility failed to ensure a Pre-Admission Screening and Resident Review was updated to include current diagnosis of psychosis for 1 resident.
F655: The facility failed to develop and implement baseline care plans within 48 hours that included problems, interventions, and initial goals for 2 newly admitted residents.
F656: The facility failed to develop and implement comprehensive care plans reflecting current needs for oxygen use and PTSD triggers for 4 residents.
F657: The facility failed to update care plans to reflect current needs for oxygen use and gastrointestinal bleeding for 2 residents.
F684: The facility failed to obtain physician orders for pressure ulcer treatments for 2 residents and failed to assess and monitor a resident for allergic reaction after administration of a medication listed as an allergy.
F686: The facility failed to obtain physician orders for pressure ulcer treatments for 2 residents and failed to complete required weekly pressure ulcer assessments for 3 residents.
F689: The facility failed to maintain wooden bedroom doors to prevent sharp edges and failed to ensure electrical outlet adapter was used according to fire prevention codes.
F695: The facility failed to provide physician ordered respiratory services including rental BiPap machine, failed to recognize use of nebulizer treatments post-PHE, failed to maintain clean respiratory equipment, and failed to obtain physician orders for oxygen use and tubing changes for 3 residents.
F699: The facility failed to identify a resident's PTSD triggers to prevent re-traumatization.
F710: The facility failed to ensure physician supervision of pressure ulcer care when physicians did not document evaluation or assessment of pressure ulcers for 3 residents.
F842: The facility failed to maintain complete, accurate, and accessible medical records including failure to document signs and symptoms for antibiotic use, inaccurate pressure ulcer staging, and inconsistent BiPap documentation for 3 residents.
F880: The facility failed to follow infection control procedures during a dressing change observation by not changing gloves and not disinfecting supplies properly.
F881: The facility failed to ensure timely notification of a negative urinalysis result to the medical provider, resulting in unnecessary continuation of antibiotic therapy for 1 resident.
Report Facts
: 72
: 43
: 104
: 141
: 88
: 92
: 93
: 2
: 3
: Jan 3, 2024
: Sep 27, 2023
: Oct 11, 2023
: Jun 15, 2023
: Oct 3, 2023
: Oct 6, 2023
: Dec 5, 2023
: Dec 6, 2023
: Jan 5, 2024
: Jan 7, 2024
Inspection Report — Jan 8, 2024
Date: Jan 8, 2024
Visit Reason
Federal Recertification Survey of Eastport Memorial Nursing Home.
Findings
The facility was found not in substantial compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition due to multiple fire safety deficiencies including inadequate fire separation walls, damaged fire doors, delayed-egress locking issues, emergency lighting failures, exit signage problems, hazardous areas enclosure deficiencies, sprinkler system maintenance lapses, and corridor door malfunctions.
Deficiencies (7)
K133: The facility failed to provide a 2-hour fire separation wall as required by NFPA 101 section 8.2.1.3; the wall had a 12-2 flexible electrical wire penetration without fire stopping and damaged/delaminating fire doors with missing fasteners.
K222: Doors in required means of egress were equipped with locking arrangements that did not meet NFPA 101 Life Safety Code 2012 requirements, potentially affecting safe egress for patients, residents, visitors, and staff.
K291: Emergency lighting was not maintained or tested as required by NFPA 101 sections 7.9 and 19.2.9.1; the emergency light near the 1st level dayroom did not work and no documentation of monthly or annual testing was provided.
K293: Exit signage was not maintained or tested per NFPA 101 section 7.10; the exit sign near the elevator control room was not illuminated.
K321: Hazardous areas enclosure was deficient; elevator control room had unsealed pipe penetrations and repairs using non-rated materials, failing to maintain required fire resistance ratings.
K353: Sprinkler system maintenance and testing were inadequate; records of system design, maintenance, inspection, and testing were incomplete, and the facility failed to ensure proper sprinkler system operation.
K363: Corridor doors failed to maintain self-closing, positive latching, and smoke resistance as required by NFPA 101 section 19.3.6.3; multiple doors did not latch properly or had holes compromising smoke barriers.
Report Facts
: 1563
: 6.33
Inspection Report — RPG821 SOD
Date: RPG821 SOD
Visit Reason
Federal Recertification Survey
Findings
The facility is not in substantial compliance with NFPA 101 Life Safety Code 2012 edition. Multiple deficiencies were found related to egress doors, exit signage, hazardous areas, cooking facilities, sprinkler system installation and maintenance, corridor doors, fire drills, electrical systems, and gas equipment storage.
Deficiencies (12)
K222: Doors at the means of egress do not meet NFPA 101 life safety code 2012 requirements for delayed egress locking systems; the Whirlpool Hallway exit door is locked against egress without proper signage or delayed egress system.
K293: Exit signage is not maintained properly; the basement level corridor exit sign is installed too low, and the dayroom exit sign does not remain illuminated when tested.
K321: Hazardous areas are not properly protected by fire barriers or automatic fire extinguishing systems as required by NFPA 101; an air vent in the hydraulic elevator machine room compromises the fire door rating, and penetrations in the fire wall are not properly sealed.
K324: The commercial cooking facility's exhaust system is not inspected or maintained properly; grease buildup inspection decal is outdated and no documentation of inspections since April 2024 was provided.
K351: The long-term care facility failed to install the water-based fire protection sprinkler system in accordance with NFPA 13 standards, potentially affecting sprinkler activation.
K353: Sprinkler system piping is not maintained free of external loads; sprinkler piping has blue internet cable zip-tied to it, which may affect system integrity.
K363: Corridor doors do not meet NFPA 101 requirements; doors lack positive latching hardware, and clearance between door bottom and floor covering exceeds 1 inch, compromising smoke resistance.
K712: Fire drills are not conducted as required; drills between 9 PM and 6 AM may use coded announcements instead of audible alarms, which is not compliant.
K761: Maintenance and inspection records for fire doors are not adequately maintained; documentation of door inspections by trained employees is lacking.
K914: Electrical receptacles at patient bed locations are not tested at required intervals; retention force of grounding blades is not ensured, posing electrical hazards.
K916: The facility failed to ensure the emergency power system annunciator is operational and that the generator has a remote annunciator monitored 24/7; generator testing and maintenance records are incomplete.
K923: Gas equipment storage areas are not properly safeguarded; oxygen cylinder storage exceeds allowed cubic feet, and cylinders are not segregated or protected from weather as required.
Report Facts
: Jan 28, 2025
: 09:00 AM to 12:15 PM
: 336
: 300
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