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Based on observation, testing, and interview, the provider failed to provide operable egress doors as required at one randomly observed exit door location (200 wing exit door). Findings include:

1. Observation beginning on 5/24/22 at 11:10 a.m. revealed the 200 wing exit door was unable to be easily opened. Testing of the door by applying greater than fifty pounds of force in the direction of the path of egress revealed it would not open.

Interview and testing at the time of the observation with the maintenance supervisor confirmed those conditions. He stated he was unaware that the door was not able to be opened.

Failure to provide working egress doors as required increases the risk of death or injury due to fire.

Based on observation and interview, the provider failed to maintain the fire-resistive design of one of one horizontal exit and building separation wall (the wall between the original building and the addition). Findings include:

1. Observation on 5/24/22 at 11:15 a.m. revealed the two-hour, fire-rated separation wall between the original building and the addition had ninety-minute, fire-rated doors that only had one point of latching. The panic bar hardware had a rod extending upward to a strike plate in the door frame. A rod had not been installed downward from the panic bar hardware to a strike plate in the floor.

Interview at 11:20 a.m. on 1/7/20 with the maintenance supervisor confirmed that condition. He verified that a thermal pin could be installed in the lower half of the two door leaves to satisfy the latching requirement.

Failure to provide working egress doors as required increases the risk of death or injury due to fire.

Based on observation and interview, the provider failed to maintain the fire-resistive design of two of two horizontal exit and building separation walls (the wall between the original building and the addition and also the wall between the original building and the long term care facility). Findings include:

1. Observation on 5/24/22 at 11:15 a.m. revealed the two-hour, fire-rated separation wall between the original building and the addition had ninety-minute, fire-rated doors that only had one point of latching. The panic bar hardware had a rod extending upward to a strike plate in the door frame. A rod had not been installed downward from the panic bar hardware to a strike plate in the floor.

Interview at 11:20 a.m. on 1/7/20 with the maintenance supervisor confirmed that condition. He verified that a thermal pin could be installed in the lower half of the two door leaves to satisfy the latching requirement.

2. Observation on 5/24/22 at 1:50 p.m. revealed the two-hour, fire-rated separation wall between the original building and the long term care facility had penetrations above the lay-in ceiling. The openings were from computer wiring installations.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the facility failed to provide a maintenance plan for piped medical gases as required. Findings include:

1. Record review on 5/24/22 at 3:30 p.m. revealed a plan to provide a medical gas outlet and system maintenance was not available. Interview with the maintenance director and associates in respiratory therapy during the facility tour on 5/24/22 revealed no planning for maintenance or repair was available.

The deficiency could impact any patients within the hospital.