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Based on observation and interview, the facility failed to maintain multiple means of egress free of obstructions. This deficient practice would delay egress and not impede it to full instant use in the case of fire or other emergencies. The facility has the capacity for 20 beds with a census of 20 on the day of survey.

Findings are:
Observations on 12-6-23 at 10:42 am revealed:
1. Storage of towels in the corridor outside room 318.
2. Patient recyclable equipment stored in the corridors.

During interview on 12-6-23 at 10:42 am, Staff A confirmed the items in the corridor. Nurse Staff A stated those items remain there all the time or until company replaces the bag.

Based on observation and staff interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. The facility has the capacity for 20 beds with a census of 20 on the day of survey.

Finding are:
Observation on 12-6-23 between 10:23 and 11:20 am, revealed the following:
1. A room within Patient Room 301 was used for storage and no door was provided, only a curtain.
2. Second floor Preop storage room measured over 50 square feet; the door failed to provide a self-closing device.
3. Second floor Preop storage room door was obstructed with medical equipment.
4. Patient room 101 was used as a storage room, no self-closing device was provided.
5. Patient room 102 was used as a storage room, no self-closing device was provided.
6. Patient room 103 was used as a storage room, no self-closing device was provided.
7. Patient room 104 was used as a storage room, no self-closing device was provided.

During interview on 12-6-23 between 10:40 am and 11:20 am, Staff A confirmed the findings.

Based on observation and interview, the facility failed to assure that patient doors would latch within the doorframe. This deficient practice would allow fire, smoke and gases to enter the exit corridor or into the room and would delay egress. The facility has the capacity for 20 beds with a census of 20 on the day of survey.

Findings are:
Observations on 12-6-23 at 10:07 am and 11:18 am revealed:
1. Patient Room 306 failed to latch within the doorframe.
2. Pantry doors in the Dining room were held open with wooden chocks.

During an interview on 12-6-23 at 10:07 am and 11:18 am, Staff A confirmed the findings.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and increase the potential for a larger fire which affected all smoke compartments and all occupants. The facility has the capacity for 20 beds with a census of 20 on the day of survey.

Findings are:
Record review on 12-6-23, at 11:55 am revealed the plan failed to include removal of items in the corridors.

During an interview on 12-6-23, at 11:55 pm, Staff A confirmed the information was not present in the fire procedure.

Based on observation and interview, the facility failed to prohibit the use of electrical adaptors. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 20 beds with a census of 20 on the day of survey.

Findings are:
Observation on 12-6-23 at 11:36 am revealed, a six-plex electrical adaptor at the ESA supply inventory manager's desk.

During an interview on 12-6-23 at 11:36 am, Staff A confirmed the use of electrical adaptor.

Based on observation and interview, the facility allowed the use of extension cords for permanent wiring. This deficient practice could increase the potential for an electrical fire. The facility has the capacity for 20 beds with a census of 20 on the day of survey.

Finding are:
Observations on 12-6-23 at 10:14 am and 11:15 am revealed:
1. A power-strip used for permanent wiring in the 3rd floor ice room.
2. An extension cord plugged into another extension cord under the food serving tables in the dining room.

During interview on 12-6-23 at 11:04 am and 11:15 am, Staff A confirmed the use of the power strip and the extension cord.