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Based on observation and interview, the facility failed to maintain means of egress free of obstructions. This deficient practice could delay evacuation during an emergency. The facility has the capacity for 25 beds with a census of 16 on the day of survey.

Findings are:
Observations on 11-30-22 at 10:18 am revealed, a wooden rocking chair stored in the LDR corridor.

During an interview on 11-30-22 at 10:18 am, Administration Staff A confirmed the rocking chair.

Based on observation and interview, the facility failed to assure that hazard room doors would close and latch within the doorframe. This deficient practice would delay closing of the door and allow the spread of fire and smoke within exit corridors. The facility has the capacity of 25 beds with a census of 16 on the day of survey.

Findings are:
Observation on 11-30-22 at 10:52 am revealed, the door to Decontamination room in the Garage failed to close and latch within the doorframe.

During an interview on 11-30-22 at 10:52 am, Maintenance Staff A confirmed the door failed to latch.

Based on observation and interview, the facility failed to assure that sprinkler components were installed as designed. These deficient practices would not allow the sprinkler system to activate as it was designed. The facility has the capacity for 25 beds with a census of 16 on the day of survey.

Findings are:
Observation on 11-30-22 at 11:36 am revealed, the lower sprinkler gauge on the main failed to provide installation date, the gauge above was replaced 10/22.

During an interview on 11-30-22 at 11:36 am Administration Staff A confirmed the gauge had not been replaced.

Based on observation and interview, the facility failed to assure doors equipped with self-closing devices would close and latch. This deficient practice would allow smoke, fire and gases to spread into the exit corridor. The facility has the capacity of 25 beds with a census of 16 on the day of survey.

Findings are:
Observation on 11-30-22 at 11:00 and 11:07 am revealed:
1. OR 3 door equipped with self-closing device failed close and latch.
2. OR 1 door equipped with a self-closing device failed to close and latch.

During an interview on 11-30-22 at 11:00 and 11:07 am, Maintenance Staff A confirmed the doors failed to latch.

Based on observation and interview, the facility failed to provide an electrical panel box directory and failed to assure electrical panel boxes were not obstructed. These deficient practices could cause a delay and injury when turning off the power during an electrical emergency. The facility has the capacity for 25 beds with a census of 16 on the day of survey.

Findings are:
Observations on 11-30-22 between 9:45 am and 10:49 am revealed:
1. Panel box in electrical room 1604 was obstructed by maintenance cart.
2. The electrical panel box GNL1 located in electrical room 1604 failed to provide a directory of circuits.
3. The electrical panel box in the CT equipment room failed to provide a directory of circuits

During an interview on 11-30-22 between 9:45 am and 10:49 am, Maintenance Staff A confirmed the missing directories and blocked panel box.

Based on observation and interview, the facility failed to post precautionary signage for oxygen storage rooms reading CAUTION: OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING This deficient practice would not warn occupants of the presence of oxygen within the storage rooms to limit the possibility of ignition sources. The facility has the capacity for 25 beds with a census of 16 on the day of survey.

Findings are:
Observation on 11-30-22 at 10:13 am revealed, precautionary sign was not posted for the Acute Care room 1661.

During an interview on 11-30-22 at 10:13 am, Maintenance A acknowledged the lack of signage.