Inspection Report Summary
The most recent inspection on August 6, 2025 identified multiple deficiencies related to electrical safety, fire safety systems, smoke-tight corridor doors, and ventilation equipment. Earlier inspections showed a consistent pattern of issues with fire safety features, electrical outlets lacking ground fault interrupters, and non-functioning exhaust fans, along with some concerns about food storage and medication administration in prior years. Complaint investigations included substantiated findings related to COVID-19 infection control failures and a substantiated incident involving improper reporting of an aggressive act toward a resident. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with physical plant and safety systems, with some recurring deficiencies over multiple years.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
10.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Dec 16, 2024 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Jun 19, 2023 | 99.75 | 3.75 | 0 | Follow-Up Inspection | |
| Apr 19, 2023 | 96 | 3.5 | 7.5 | Annual Inspection | |
| Feb 2, 2022 | 90 | 2.5 | 0 | Monitoring Visit | |
| Dec 10, 2021 | 87.5 | 0 | 10 | Monitoring Visit | |
| Aug 25, 2021 | 97.5 | 3.5 | 6 | Annual Inspection | |
| May 5, 2021 | 96 | 0 | 3.5 | Complaint Investigation | |
| Apr 22, 2020 | 99.5 | 3.5 | 4 | Annual Inspection | |
| Mar 5, 2019 | 86.5 | 2.5 | 0 | Follow-Up Inspection | |
| Oct 16, 2018 | 84 | 0 | 9 | Follow-Up Inspection | |
| May 8, 2018 | 93 | 0 | 7 | Follow-Up Inspection | |
| Jan 22, 2018 | 100 | 5.5 | 5.5 | Annual Inspection | |
| Jan 21, 2015 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Oct 18, 2012 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Jun 21, 2011 | 101.5 | 5.5 | 4 | Annual Inspection | |
| May 5, 2010 | 99.5 | 3.5 | 4 | Annual Inspection | |
| May 21, 2009 | 99.5 | 5.5 | 6 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Aug 6, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously noted deficiencies and to identify any new deficiencies.
Findings
The facility was found to have multiple deficiencies including lack of ground fault interrupters on electrical outlets in wet locations, unsafe and non-operating smoke-tight corridor doors, gaps in fire rated ceiling assemblies, fire alarm control panel trouble indications, and numerous exhaust fans not working throughout the facility.
Deficiencies (5)
Electrical outlets in wet locations near washing machines lacked ground fault protection.
Smoke-tight corridor doors were not maintained in a safe and operating condition, including splitting door frames and doors requiring excessive force to close or not closing.
Gaps around cable penetrations in fire rated ceiling assemblies and holes in ceilings compromising fire safety.
Fire Alarm Control Panel indicated trouble with duct detector and power/supply charger issues.
Exhaust fans in multiple bathrooms, laundries, and housekeeping areas throughout the facility were not working.
Report Facts
Diameter of hole in ceiling: 4
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey of Legacy Heights Senior Living Community on October 13-14, 2024.
Findings
The facility failed to ensure food stored and served to residents was protected from contamination, with multiple instances of unlabeled and undated food items and ceiling vents covered with black and gray particles. The kitchen vents and storage vents required cleaning and repair.
Deficiencies (1)
Food stored and served was not protected from contamination due to unlabeled and undated food items and ceiling vents covered with black and gray particles.
Report Facts
Survey dates: 2
Storage life days: 2
Storage life days: 3
Storage life days: 13
Storage life weeks: 3
Observation date: Nov 13, 2024
Observation date: Nov 14, 2024
Inspection Report
Deficiencies: 4
Date: Feb 13, 2024
Visit Reason
The report documents a biennial construction section survey conducted to assess compliance with building codes and adult care home regulations.
Findings
Multiple deficiencies were identified including lack of ground fault interrupters in electrical outlets near water sources, smoke-tight corridor doors not fitting properly, fire safety systems and emergency equipment not maintained in safe operating condition, and numerous exhaust fans in bathrooms, laundries, and housekeeping areas not working.
Deficiencies (4)
Electrical outlets in wet locations lacked ground fault interrupters; GFCI receptacles were not energized or did not trip on test.
Smoke-tight corridor doors had gaps preventing proper fitting into frames.
Fire safety systems including fire alarm control panel and emergency exit signs were not maintained in safe operating condition.
Exhaust fans in multiple bathrooms, laundries, and housekeeping areas were not working.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 9, 2023
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual and follow-up survey from March 7, 2023 through March 9, 2023.
Findings
The facility failed to provide adequate supervision for a high-risk resident with multiple falls resulting in head injuries, failed to administer medications as ordered for two residents, including omission of a medication for indigestion and inaccurate medication administration records for blood pressure and vitamin D treatments.
Deficiencies (4)
Failed to provide supervision for Resident #4 who required assistance with toileting and had a history of falls, resulting in multiple falls with head injuries and hospitalizations.
Failed to administer omeprazole (medication for indigestion, acid reflux, and heartburn) as ordered for Resident #1, with no administration documented from 02/14/23 through 02/28/23 despite no discontinuation order.
Medication administration records were inaccurate for Resident #6 related to metoprolol succinate ER 50mg for high blood pressure; an incorrect transcription led to administration of the wrong dose documentation though the correct medication was given.
Failed to administer vitamin D 25mcg daily as ordered for Resident #1; no documentation of administration and medication was not given during the review period.
Report Facts
Fall risk score: 80
Number of falls: 4
Medication doses missed: 15
Medication doses remaining: 13
Medication doses missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Resident Care Director | Assistant Resident Care Director (ARCD) | Responsible for auditing fall reports and rounding sheets, but audits were not conducted since 01/01/23. |
| Resident Care Director | Resident Care Director (RCD) | Responsible for reviewing incident reports, auditing medication charts, and ensuring care plans but unaware of some deficiencies. |
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for entering incident reports into computer and auditing rounding sheets. |
| Administrator | Facility Administrator | New to position, unaware of QAPI use and some care plan meetings; responsible for root cause analysis. |
| Medication Aide | Medication Aide (MA) | Responsible for completing incident reports and administering medications; unaware of some medication order changes. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: May 19, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual, follow-up, and complaint investigation survey on May 18-19, 2021.
Complaint Details
The complaint investigation included allegations of abuse to Resident #1, specifically that a staff member struck the resident. The investigation found the resident was not struck but was aggressively struck with a teddy bear. The incident was not timely reported by staff witnesses. The facility terminated the involved staff. The facility failed to provide the required five-day report to the Health Care Personnel Registry investigator.
Findings
The facility was found deficient in multiple areas including failure to update resident assessments and care plans after significant changes, failure to ensure physician referral and follow-up for medications, failure to provide timely reports to the Health Care Personnel Registry for alleged abuse, failure to provide required disclosure information for admission to the Special Care Unit, and failure to ensure medication aides completed required training.
Deficiencies (5)
Failure to ensure an assessment and care plan was updated within 10 days following a significant change for a resident who declined in ambulatory status.
Failure to ensure referral and follow-up with the physician for residents related to medication orders and administration.
Failure to provide a five-day report to Health Care Personnel Registry for alleged abuse to a resident.
Failure to ensure disclosure information regarding policies and procedures in the Special Care Unit was provided to and signed by family members or guardians for residents admitted to the SCU.
Failure to ensure completion of required medication aide training for a staff member administering medication.
Report Facts
Sampled residents: 5
Medication administration dates: 28
Staff training date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Administered medication without documented completion of required medication aide training. |
| Administrator | Responsible for oversight of care plans, reporting, and staff training; involved in interviews and report submissions. | |
| Business Office Manager | Responsible for maintaining employee records and training documentation; unable to locate medication aide training for Staff A. | |
| Regional Operations Specialist | Assisted with obtaining physician orders and clinical support during staff vacancies. | |
| Resident Care Coordinator (RCC) | Responsible for completing care plans and admission paperwork; position vacant during survey. | |
| Wellness Secretary | Assisted with paperwork but did not review SCU disclosure information with families. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Date: Mar 9, 2021
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a complaint investigation with onsite visits on 03/03/21 and 03/05/21, and a telephone exit on 03/09/21 regarding COVID-19 infection prevention and control practices.
Complaint Details
Complaint investigation triggered by concerns about COVID-19 infection prevention and control practices during an outbreak at the facility, including testing and cohorting failures.
Findings
The facility failed to implement and maintain CDC, NC DHHS, and local health department COVID-19 guidance during an outbreak, including weekly testing of residents and staff and cohorting of COVID-19 positive residents with dedicated staff. Residents who tested positive were not cohorted in designated areas, and staff provided care to both positive and negative residents without proper separation, increasing risk of transmission.
Deficiencies (3)
Failure to ensure implementation of CDC, NC DHHS, and local health department COVID-19 guidance including weekly testing and retesting of residents and staff during an outbreak.
Failure to cohort residents with confirmed or suspected COVID-19 diagnoses in designated areas with dedicated staff.
Failure to provide care and services adequate and appropriate to infection prevention and control requirements during COVID-19 outbreak.
Report Facts
Special Care Unit census: 33
Residents tested for COVID-19: 16
Staff tested for COVID-19: 7
Staff not tested for COVID-19: 4
Residents tested positive for COVID-19: 8
Residents not documented as tested: 16
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 15, 2020
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on January 14-15, 2019 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to implement physician orders to obtain a pulse prior to administering medication for one resident, and failed to administer the correct dose of a medication for gastroesophageal reflux disease for the same resident. Documentation and communication errors with the pharmacy and medication aides contributed to these deficiencies.
Deficiencies (2)
Failed to implement orders to obtain a pulse prior to administering medication for one resident with pulse parameters.
Failed to administer medications as ordered for one resident related to a medication used to treat gastroesophageal reflux disease (GERD).
Report Facts
Medication administration opportunities: 90
Medication administration opportunities: 93
Medication administration opportunities: 39
Medication dose: 20
Medication dose: 40
Medication quantity: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Director of Resident Care | Responsible for reviewing MARs and ensuring documentation and medication orders were accurate |
| Wellness Nurse | Wellness Nurse | Checked MARs monthly and responsible for faxing orders to pharmacy |
| Administrator | Administrator | Oversaw medication administration policies and expected staff to follow orders and conduct audits |
| Medication Aide | Medication Aide | Failed to document pulse and administered incorrect medication dose due to oversight |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 28, 2018
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted a follow-up survey on 06/26/18-06/28/18 to assess compliance with health care referral, medication administration, and follow-up requirements.
Findings
The facility failed to assure health care referral and follow-up for 3 of 9 sampled residents related to medication crushing orders and fingerstick blood sugar (FSBS) results outside parameters without physician notification. Medication administration errors were observed in 7 of 9 residents, including insulin administration errors, failure to administer ordered medications, and failure to follow medication administration policies. Documentation errors on the Medication Administration Record (MAR) were also noted.
Deficiencies (4)
Failed to assure health care referral and follow-up for medication crushing orders and FSBS results outside parameters without physician notification for 3 residents.
Failed to administer medications as ordered including insulin errors, antibiotic and acid reducing medication errors, failure to administer supplements and PRN medications, and failure to follow medication administration policy requiring MAR review.
Failed to maintain accurate documentation on the MAR for administration of Eliquis, iron sulfate, and colchicine.
Failed to assure every resident's right to receive adequate and appropriate care and services in compliance with laws and regulations related to medication administration and health care.
Report Facts
Medication error rate: 32
Residents sampled: 9
Residents with medication errors: 7
Residents with health care referral failures: 3
Medication administration errors observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Provided training to medication aides on medication administration and follow-up; unaware of medication administration errors. |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Reviewed FSBS readings but did not review for blood glucose parameters or notify physician of out-of-range values. |
| Resident Services Director | Resident Services Director (RSD) | Responsible for training medication aides on medication administration and diabetes care. |
| Administrator | Facility Administrator | Expected staff to follow medication administration policies and procedures; unaware of medication errors and documentation issues. |
| Medication Aide | Medication Aide (MA) | Multiple medication aides interviewed; several unaware of proper medication administration procedures including insulin pen priming and MAR review. |
| Primary Care Physician | Primary Care Physician (PCP) | Unaware of medication administration errors and lack of physician notification for out-of-range FSBS results. |
| Memory Care Resident Care Coordinator | Memory Care Resident Care Coordinator (MCRCC) | Responsible for reviewing MARs; unaware of missing medications on MAR. |
| Wellness Director | Wellness Director (WD) | Completed final MAR checks; unaware of missing medications on MAR. |
| Health and Wellness Director | Health and Wellness Director (HWD) | Aware of MAR documentation errors for Eliquis. |
| Pharmacist | Pharmacist | Provided training on medication administration; noted errors in medication orders entered into pharmacy system. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 26, 2018
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
The corridor was found not to be maintained free of obstructions, with two medication carts stored in the second floor corridor reducing the clear width to 3 feet 4 inches, which is below the required 6 feet clearance.
Deficiencies (1)
Corridors were not free of equipment and obstructions, reducing clear width to 3 ft. 4 inches instead of the required 6 feet.
Report Facts
Clear corridor width: 3.33
Required corridor clearance: 6
Inspection Report
Routine
Deficiencies: 30
Date: May 10, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were identified related to physical plant, safety, housekeeping, fire safety, and equipment maintenance in both the Assisted Living and Special Care Buildings. Issues included improperly marked and locked exits, corridor obstructions, fire safety system malfunctions, housekeeping hazards, improper storage, and failure to maintain required exhaust ventilation and heating system standards.
Deficiencies (30)
Central exits marked with exit signs were locked with electronic strikes not meeting Special Locking requirements.
Delayed Egress exit door lacked required signage.
Corridors were obstructed reducing required clear width; some obstructions corrected during survey.
Excessive lint and dirt accumulation on exhaust register and radiation damper in laundry.
Laundry doors had locks trapping occupants inside.
Improper storage too close to fire sprinkler heads negating fire suppression ability.
Extension cords used in place of permanent wiring.
Portable medical oxygen cylinders improperly stored in unapproved containers.
Electric baseboard heater cover improperly mounted presenting laceration hazard.
Shower wand hose lacked vacuum breaker risking water contamination.
Ice machine drain line improperly installed risking contamination.
Toilet loosely mounted presenting leak and fall hazards.
Missing inside door knob on storage closet risking entrapment.
Exit signs directing exiting in wrong directions.
No documentation of monthly inspection on range hood fire suppression system for April.
Loose floor drain cover presenting trip and fall hazard.
Fire alarm system showing 'System Trouble' condition.
Corridor doors prevented from closing and latching properly, compromising fire and smoke resistance.
Sampling tubes for duct mounted smoke detectors dirty or improperly installed.
Smoke detectors delayed activation when tested with smoke.
One-hour fire rated walls and ceilings compromised by holes, penetrations, and missing fire collars.
Improperly fitted or missing sprinkler escutcheons compromising fire rated ceilings.
Battery powered emergency lights failed to work properly in multiple stairwells.
Exit signs failed to work on battery power in multiple locations.
Junction box on wet side sprinkler valve hanging by wires.
Faulty Delayed Egress lock failed to unlock on fire alarm activation.
GFCI receptacles failed to trip when tested, presenting shock risk.
Emergency receptacle hanging partly out of wall.
Portable electric heater found in copy room, violating prohibition.
Exhaust ventilation failed to operate properly in multiple specified areas.
Report Facts
Number of portable medical oxygen cylinders improperly stored: 8
Number of sprinkler escutcheons missing: 3
Number of sprinkler escutcheons missing: 3
Inspection Report
Follow-Up
Deficiencies: 3
Date: Mar 8, 2018
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County DSS conducted a follow-up survey on March 7-8, 2018 to verify correction of previous deficiencies related to medication administration and notification of primary care providers.
Findings
The facility failed to assure the primary care provider was notified regarding medications not administered as ordered for 4 of 7 residents, and failed to assure medications were administered as ordered for 5 of 7 residents. Documentation on the Medication Administration Record (MAR) was also inaccurate for 2 residents. These failures were detrimental to resident health and safety and constitute a Type B Violation.
Deficiencies (3)
Failure to notify primary care provider regarding medications not administered as ordered for 4 of 7 residents related to thyroid medication, antidepressant, and blood thinner.
Failure to administer medications as ordered by physician for 5 of 7 residents related to thyroid medication, antidepressant, blood thinner, missing medications, and fast acting insulin.
Failure to assure accurate documentation on the Medication Administration Record (MAR) for 2 residents related to levothyroxine sodium and warfarin sodium.
Report Facts
Missed doses of levothyroxine sodium: 6
Missed doses of citalopram hydrobromide: 4
INR lab result: 3.1
INR lab result: 1.22
Missed doses of warfarin: 2
Missed doses of warfarin: 4
Incorrect insulin doses: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Unit Director | SCU Director | Interviewed regarding medication administration and audits. |
| Special Care Unit Resident Care Coordinator | SCU RCC | Interviewed regarding medication administration and audits. |
| Administrator | Interviewed regarding expectations for medication administration and notification. | |
| Assisted Living Resident Care Coordinator | AL-RCC | Interviewed regarding medication administration and refill processes. |
| Resident Service Director | RSD | Interviewed regarding medication administration and refill processes. |
| Registered Nurse | RN | Interviewed regarding monitoring of warfarin therapy for Resident #6. |
| Medication Aide | MA | Multiple MAs interviewed regarding medication administration and notification responsibilities. |
| Wellness Nurse | WN | Interviewed regarding medication administration oversight. |
| Pharmacist | Interviewed regarding medication dispensing and refill requests. | |
| Primary Care Physician | PCP | Interviewed regarding expectations for medication administration and notification. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 16, 2017
Visit Reason
The Adult Care Licensure Section and the Mecklenburg County Department of Social Services conducted an annual survey on November 14-15, 2017 with a telephone exit on November 16, 2017.
Findings
The facility failed to administer medications as ordered for 1 of 4 residents observed during medication passes and 3 of 7 sampled residents, including errors with blood pressure medication, sliding scale insulin, thyroid supplement, anxiety medication, and medication for fluid retention. This failure put residents at risk for adverse health effects including increased blood pressure, hypoglycemia, falls, agitation, and hypothyroid symptoms.
Deficiencies (4)
Failed to administer furosemide 20 mg as ordered for Resident #8, resulting in missed anti-hypertensive medication and potassium supplement administration.
Failed to administer furosemide 40 mg at the correct time (2:00 pm) for Resident #3, increasing risk of falls.
Failed to administer sliding scale insulin as ordered for Resident #2, with multiple missed or undocumented doses.
Failed to administer thyroid supplement (levothyroxine) and medication for anxiety (fluoxetine) as ordered for Resident #7, with excess medication remaining on hand.
Report Facts
Medication error rate: 6
Medication administration opportunities: 29
Sliding scale insulin missed doses: 8
Fluoxetine capsules on hand: 57
Levothyroxine tablets on hand: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for reviewing physician orders, MAR accuracy, and medication administration oversight; interviewed multiple times regarding medication errors and documentation. |
| Resident Services Director | Resident Services Director (RSD) | Responsible for assuring medications were administered as ordered and staff training; interviewed regarding medication administration failures. |
| Medication Aide | Medication Aide (MA) | Multiple medication aides interviewed regarding medication administration and documentation errors. |
| Executive Director | Executive Director (ED) | Interviewed regarding facility expectations for medication administration and documentation. |
| Memory Care Director | Memory Care Director | Responsible for medication cart audits and MAR accuracy; interviewed regarding medication discrepancies for Resident #7. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 5, 2016
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies.
Findings
The fire safety was not maintained in a safe and operating condition due to unsealed PVC vents penetrating fire-resistance-rated ceiling assemblies in two furnace rooms, allowing potential spread of fire and smoke.
Deficiencies (2)
Two large PVC vents in SCU 'C' Hall Furnace Room were not firestopped, allowing spread of fire and smoke.
Two large PVC vents in SCU 'D' Hall Furnace Room were not firestopped, allowing spread of fire and smoke.
Inspection Report
Deficiencies: 15
Date: Jun 22, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, 2005 Rules for Adult Care Homes, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including lack of hand grips in bathrooms, poor housekeeping and maintenance issues, fire safety hazards such as improperly maintained fire extinguishers, sprinkler system deficiencies, fire-resistance-rated construction penetrations, malfunctioning emergency exit signs, unsafe interior doors, electrical hazards, prohibited portable electric heaters, and inadequate exhaust ventilation in certain areas.
Deficiencies (15)
Facility failed to provide hand grips at commodes, tubs, and showers accessible to residents.
Walls, ceilings, and floors or floor coverings were not kept clean and in good repair; strong urine odor present in SCU 'D' Hall Bathroom; sheet vinyl curling in SCU 'A' Hall Exit Corridor.
Facility failed to maintain building in an uncluttered, clean, and orderly manner free of hazards; excessive dust/lint on HVAC return grille; backflow hazard due to lack of vacuum breakers on specialty tubs and showers.
Fire extinguishers and associated equipment not properly maintained; fire extinguisher gauge indicated recharging needed.
Building sprinkler system not maintained in safe and operating condition; multiple fire sprinkler escutcheon plates missing or not covering holes, allowing passage of fire and smoke.
Fire safety not maintained; large PVC vents not firestopped allowing spread of fire and smoke.
Interior doors not maintained in safe and operating condition; smoke seals deteriorated; corridor doors not latching or closing properly allowing passage of smoke.
Fire alarm system not maintained in safe and operating condition; dirty smoke detector sample tubes.
Fire-resistance-rated construction penetrated with unsealed openings and inappropriate materials allowing passage of fire and smoke.
Emergency exit signs and emergency lights not working on backup power; exit signs with misleading directional graphics.
Electrical panel access blocked by stored items.
Corridor doors held open with wedges or weights preventing rapid closure and latching.
Commercial kitchen hood fire extinguishing system lacked monthly inspection records since last semi-annual maintenance in March 2016.
Use of prohibited portable electric space heater found in 1st Floor 'C' Hall Bedroom C7.
Facility failed to provide exhaust ventilation in areas where odors are generated or required, including 2nd Floor Housekeeping and SCU Bio Hazard Room.
Report Facts
Date of survey completion: Jun 22, 2016
Semi-annual maintenance date: 201603
Number of penetration issues: 4
Number of penetration issues: 2
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