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Based on observation and interview, the facility failed to maintain egress doors in proper working order by having a twist type lock installed on the door. This could affect 1 resident in the facility. The facility has a capacity of 25 and a census of 1.

Findings include:

Observation and interview on 6/7/2021 at 10:45 a.m., revealed Resident Room door #101 contained a standard door knob with a twist type lock that requires special manipulation to open the door. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain egress doors in proper working order by having a twist type lock installed on the door. This could affect 1 staff in this room. The facility has a capacity of 25 and a census of 1.

Findings include:

Observation and interview on 6/7/2021 at 10:01 a.m., revealed the Material Storage Room door contained a standard door knob with a twist type lock that requires special manipulation to open the door. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to install battery powered lighting in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.2.2.11.1), 2012 Edition. This deficient practice affects all patients receiving deep sedation and general anesthesia. The facility has a capacity of 25 and a census of 1.
Findings include:
Observation and interview on 6/7/2021 at 11:00 a.m., revealed the facility failed to provide battery backup emergency lighting in three of three of Operating Rooms. The battery powered lighting units are required in the event that there is a loss of power and the emergency generator would fail to operate properly. The Surgery Supervisor and Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure the sprinkler system is installed properly. The facility failed to have sprinkler head coverage in the Water Service Room. This affects one resident in the facility with a capacity of 25 with a census of 1.

Findings include:

1. Observation and interview on 6/7/2021 at 9:55 a.m., revealed the Water Service Room failed to contain any sprinkler head coverage. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 6/7/2021 at 10:11 a.m., revealed the X-Ray Corridor contained mixed sprinkler heads that could affect the sprinkler head spray patterns. This corridor contained two fusible link and three quick response heads. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 1.

Findings include:

Observation and interview on 6/7/2021 at 9:57 a.m., revealed the facility failed to maintain the sprinkler system in the Water Service Room. This room contained red wires zip tied to the sprinkler pipe. The Maintenance Director verified this observations at the time of the survey process.