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Based on observations and staff interview, the facility failed to ensure 2 exit access doors were equipped with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions in accordance with the code at 7.2.1.5.4. This could potentially affect all staff and patients in the facility. The patient census on the first survey day was 59.

Findings include:

A tour of the third floor was conducted with Staff A1 and D4 on 12/12/12 between 10:08 A.M. and 10:25 A.M. Two exit access doors (S349 and S347) to respiratory therapy were observed with locking devices that required a two step method to unlock the doors and exit the rooms. These locking devices were observed located approximately 1 foot above the door handles. In order to enter these rooms, a keypad code had to be entered into the locking mechanism and a flip latch had to be turned, before turning the door handle. In order to exit the rooms, the flip latch had to be turned and held in place to clear the strike plate, and the door handle had to be turned at the same time. Staff A1 verified these door locks were difficult to use in order to exit the rooms.

Based on documentation review and staff verification it was determined this facility failed to ensure the sprinkler system was tested quarterly as required by the National Fire Protection Association (NFPA), Chapter 25, 2-1. The facility also failed to ensure generator test reports were available for review in order to verify the weekly visual inspections and monthly load tests according to NFPA 99 and 110.
This had the potential to affect all those utilizing this facility. The patient census the first day of the survey was 59.

Findings include:

Documentation review of the sprinkler system testing took place on 12/13/12 with staff members B2 and C3. During review, it was determined the facility lacked documentation of quarterly sprinkler inspection reports. The last inspection report available was an annual inspection dated 10/02/12. Interview with Staff C3 revealed the facility has not been performing quarterly sprinkler inspections, stating the facility had components which should be inspected quarterly.

During documentation review on 12/13/12, the facility Staff C3 and B2 verified the facility lacked documented evidence the weekly visual inspections and monthly load tests had been performed, in regards to the generator. Both aforementioned staff verified the generator logs for weekly and monthly inspections was not available.