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Based on observation and interview, the provider failed to provide unobstructed paths of egress for two randomly observed exit discharge locations (west patient wing exit discharges). Findings include:

1. Observation on 9/10/24 at 9:30 a.m. revealed the west patient wing north and south exit discharges were approximately 50% overgrown with weeds on both sides of the sidewalks. The weeds on both sides of the sidewalk were extending approximately 25% on each side of the 48 inch wide sidewalks and obstructed the path of egress.

Interview at the time of the observation with the environmental services director confirmed those conditions. He stated the landscaping from recent building construction was not yet completed and was unaware the plant growth was extending over the sidewalks.

The deficiency affected 100% of the smoke compartment occupants.

Based on observation and interview, the provider failed to install an illuminated exit sign for one random location in the patient wing (north corridor westerly direction). Findings include:

1. Observation on 9/10/24 at 9:00 a.m. revealed the north corridor of the patient wing heading west did not have an illuminated exit sign showing the path of egress in an emergency.

Interview with the environmental services director at the time of the observation confirmed that finding. He stated a sign had not been installed since the new building was constructed.

The deficiency affected one location required to be provided with a marked and identifiable path of egress.

Based on observation and interview, the provider failed to maintain the fire alarm system as required for calendar year 2024 (patient wing smoke detection). Findings include:

1. Observation on 9/10/24 beginning at 9:15 a.m. revealed the smoke detector in the environmental services closet had a plastic cover on the smoke detector. The plastic cover negated the functionality of the smoke detector. Further observation revealed a plastic cover on the smoke detector in the soiled utility room in the south patient wing corridor OB wing and a plastic cover on the smoke detector in the emergency equipment storage room in the south patient wing.

Interview with the environmental services director at the time of the observations confirmed those findings. The plastic covers were removed during the survey.

Failure to maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency had the potential to affect 100% of the building occupants.

Ref: 2012 NFPA 101 Section 19.3.4.1, 9.6.1.5; 2010 NFPA 72 Section 14.6.2.4, Figure 14.6.2.4 Section 7.12-7.14 and page 11 of 11)

Based on observation and interview, the provider failed to maintain corridor protection with doors equipped with positive latching hardware at one randomly observed location (construction room). Findings include:

1. Observation on 9/10/24 at 9:45 a.m. revealed the door to the construction room from the corridor close to the kitchen location was not equipped with positive latching hardware.

Interview with the environmental services director at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants of the smoke compartment.