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Based on observation, the facility failed to properly maintain patient sleeping room doors as directed by NFPA Chapter 19 2.2.2.5. This condition practice affected the entire facility on the day of survey.


Findings include:

On April 25, 2018 at 10:15 AM, observation revealed double keyed dead bolts on the following corridor doors in the facility:

1. Patient Rooms 119, 120, 122, 124, 126, 127, 128, 129, and 130
2. Both corridor doors to the Wound Care Treatment Room

These double keyed dead bolts on the corridor doors restricted means of egress of the patient side of the rooms.

Based on observation, the facility failed to properly maintain exit egress as directed by NFPA Chapter 19 2.2.2.4. This standard deficiency affected one (1) of eight (8) exits in the facility on the day of survey.


Findings include:

On April 25, 2018 at 10:10 AM, observation revealed the egress doors from each end of the Senior Care Area was blocked by key locked doors. The staff members did obtain a key to the locked doors leading to/from the Senior Care Area of the facility. Observation also revealed the egress door from the Senior Care Area exited into the Main hospital swung did not swing in the direction of exit travel.

Based on observation, the facility failed to properly maintain exit discharge as per NFPA 19.2.5.2. This condition affected one (1) of eight (8) exits in the facility on the day of survey.

Findings include:

On April 25, 2018 at 11:00 AM, observation revealed a dead end corridor near X-Ray Room of the facility. The dead end corridor was 43 feet in distance and was created by padlock corridor door to the exterior of the X-Ray Area. The area and floor leading through the padlocked door was being used as storage and considered an unsafe environment.

Based on observation, the facility failed to properly maintain exit egress as per S&C letter 05-38.
This condition affected five (5) of eight (8) exits in the facility on the day of survey.

Findings include:

On April 25, 2018 between 10:00 AM and 11: 25 AM, observation revealed the following exits were obstructed and lacked an all weather surface leading to the public way (sidewalk) of the facility:

1) Senior Care Unit exit
2) Exit near Room 139
3) Surgery Exit
4) Exit near the IT Room
5) Exit near X-ray Room

Based on observations, the facility failed to provide a complete manual fire alarm system in accordance to NFPA Chapter 72 section 18.5.4.4.7. This standard deficiency practice affected the entire facility on the day of survey.

Findings include:

On April 25, 2018 at 12:10 PM, observation revealed the visual fire alarm signaling devices at the Nurses' Station were not synchronized.

Based on observations, the facility failed to properly provide smoke barrier walls for the purpose of providing one half hour fire resistance in accordance NFPA 101 section 19.3.7.3. This condition deficiency practice affected entire facility on the day survey.

Findings Include:

On April 25, 2018 at 1:00 PM, observation and interviewing revealed the facility and staff was unable to identify and located the smoke barrier walls in the facility.