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Based on observation and staff interview, the facility failed to maintain one stair exit free of obstruction in accordance with the NFPA 101, 2012 edition 19.2.1, 7.1.10.1. This deficient practice could affect an undetermined number of staff and patients who receive care in the facility.

Findings include

On 07/26/21 at 10:20 am, observation revealed that the exit door into Stair E across from Room 2.055 on the 2nd Floor East unit was obstructed with one approximately 4 foot high cart placed in front of door on the corridor side.

The above deficient practice was verified with Staff D (director of plant operations) at the time of discovery, and Staff C (administrator) at the time of the exit conference.

Based on observation and staff interview, the facility failed to provide free egress into exit stairs in accordance with the NFPA 101, 2012 edition 18.2.2.2.4. This deficient practice affected 1 of 30 patients in the facility.

Findings include

On 07/26/21 between 10:36 am and 10:44 am, observation revealed that required exits into Stair A and Stair B were key-locked from the egress side. This arrangement did not provide free egress into required exit stairs.

The above deficient practice was confirmed with Staff D (director of plant operations) at the time of discovery, and with Staff C (administrator) at the time of the exit conference.

Based on observation and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with the NFPA 101, 2012 edition 18.3.4.1, 9.6.1.3, NFPA 72 2010 edition Table 14.4.2.2(14)(g). This deficient practice could affect an undetermined number of staff and patients who receive treatment in the facility.

Findings include

On 07/26/21 at 10:41 am, observation revealed that two ceiling-mounted system smoke detectors in the corridor adjacent to Stair A on 3rd Floor were covered with orange color plastic covers blocking the entry of smoke into the sensing chambers in fire emergencies.

The above deficient practice was verified with Staff D (director of plant operations) at the time of discovery, and Staff C(administrator) at the time of the exit conference.

Based on observation and staff interview, the facility failed to provide essential electrical power system in one of three patient sleeping units in accordance with the NFPA 101, 2012 edition 18.5.1.3, 9.1.2, NFPA 99-2012 6.5.1, 6.4.1.1.4, NFPA 70-2011 517.35, 517.18(A). This deficient practice affected 1 of 30 patients in the facility.

Findings include

On 07/26/21 at 10:45 am, observation with Staff D revealed that the patient Room 3.024 on 3rd Floor West did not have electrical receptacles supplied by emergency power, and that all six wall receptacles in the room were on a normal power branch circuit. This deficient practice was confirmed with Staff D (director of plant operations) at the time of discovery, and with Staff C (administrator) at the time of the exit conference.