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Based on observation and record review, the facility failed to ensure that all fire barrier doors have been inspected for the annual fire door inspection. This deficient practice could potentially affect 19 of 19 patients in the facility

Findings:

During facility tour between the hours of 8:00am and 4:00pm, it was observed, that after reviewing documentation and speaking with maintenance director, that no fire door inspections have been conducted on the facility. This is an annual required inspection per NFPA 80 7.2.1.15.

Interview with Administrator revealed the facility was unaware the fire doors required annual inspection.

Based on visual observation the facility failed to ensure that doors in a required means of egress were kept free from obstruction and shall not be equipped with a latch or lock that requires use of a key or tool.

Findings:

During facility tour between the hours of 8:00am and 4:00pm, it was observed, that the doors entering general surgery area were locked with a keyed masterlock. The lock was only accessible from the outside and only one person had a key.

Interview with Administrator revealed the facility was unaware the lock was on the general surgery doors.

Based on visual observation the facility failed to assure that each smoke compartment was provided with an exit leading directly to the outside of the building. When all exits provide free egress occupants remain calm and evacuate safely. This deficiency has the potential to affect 19 of 19 residents.

Findings:

During the facility tour, between the hours of 8:00am and 4:00pm, it was observed that the corridor housing patients did not have an exit leading directly to the outside. Due to construction on the facility the nearest exit was over 300 feet away. Dead end corridors can not exceed 30 feet. Travel distance can not exceed 100 feet to a marked exit.

Interview with Administrator revealed the facility was not aware that the corridor was not accessible.

Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The deficient practice had the potential to affect 19 of 19 residents.
The exit discharge was deficient on patient corridor.

Findings:

During the facility tour, between the hours of 8:00am and 4:00pm, it was observed, that due to construction the exit leading out patient corridor was not accessible. Once exiting the door there is no all weather level travel surface leading to public way. This is due to construction currently being done to the facility and the sidewalk was removed.

Interview with Administrator revealed the facility was not aware that the exit discharge did not continue to the public way.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 19 of 19 patients.

Findings:

During the facility tour, between the hours of 8:00am and 4:00pm, it was observed that electrical outlets in Emergency Department rooms 5 and 6 were not grounded.

Interview with Administrator revealed the facility was not aware of the electrical outlets that were not grounded.