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Based on document review, observation and interview, the facility failed to ensure emergency exit doors were accessible as means of exit at all times for 4 of 4 exit doors (see tag 720).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure a safe physical environment was provided.

Based on document review, observation and interview, the facility failed to keep patient safe from harm and provide a safe way to exit the building in an emergency.

Findings include:

1. Review of policy titled Patient Rights and Responsibilities, PolicyStat ID: 10359862, last revised 09/2021, states on number 29, it indicates Patients have the right to receive "humane care and protection from harm."

2. On observation of 10/25/2022, between approximately 9:45 am, and 10:46 am, with A1 (Director of Quality, Risk,Compliance) and A4 (Director of Nursing) the following was observed. Outside exit door on unit 100 and 200 were locked and unable to be unlocked by key or electronic key fob. When A4 attempted to unlock the exit door it failed to unlock.

3. Interview on 10/25/2022 at approximately 10:45 am. with A4 (Director of Nursing) indicated that the exit doors on 100, 200, 300 and 400 units only open when the fire alarms are activated and A2 (Chief Executive Officer) has a key to access the exit door. Confirmed there is not a key left in the building for the exit doors.

Based on document review, observation and interview, the facility failed to ensure 4 of 4 emergency exit doors were readily accessible at all times.

Findings include:

1. LSC 101 at 21.2.2.1 states components of means of egress shall be limited to the types described in 39.2.2. 39.2.2.2.1 states doors complying with 7.2.1 shall be permitted. LSC 7.2.1.6.2(3)(a) states door assemblies in the means of egress shall be permitted to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met: 3 Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria: (a) The manual release device shall be located on the egress side, 40 in. to 48 in. vertically above the floor, and within 60 in. of the secured door openings. This deficient practice could affect being able to exit the building in an emergency situation.

2. Review of the facility policy titled Fire Plan (Code Red), Policy Stat ID: 9880061, Last revised 05/2021: The following objectives will prevent human injuries, maintain a physical environment free of physical hazards and safeguard property. #5. To provide adequate exit and means of egress lighting.

3. On observation of 10/25/2022, between approximately 9:45 am, and 10:46 am, with A1 (Director of Quality, Risk, Compliance) and A4 (Director of Nursing) the following was observed. Outside exit door on unit 100 and 200 was locked and unable to be unlocked by key or electronic key fob. When A4 attempted to unlock the exit door it failed to unlock.

4. On interview of 10/25/2022, at approximately 10:00 am, with A4 (Director of Nursing) confirmed the items found above on observation from 9:45 am, through 10:46 am. He/she also states that the 100, 200, 300 and 400 unit exit doors only open when the fire alarms are activated and A2 (Chief Executive Officer) has a key to access the exit door. Confirmed there is not a key left in the building for the exit doors.

Based on document review, observation and interview, the facility failed to provide paper towels in 6 (six) (106, 108, 109, 205, 206 and 207) occupied patient room bathroom sinks and 2 (two) sinks located in the common area designated for dining to dry hands after hand hygiene.

Findings include:

1. Review of facility policy, Hand Hygiene-CDC Guidelines: PolicyStat ID: 9158116, Last Review/Revision: date 01/2020. Purpose to provide guidelines for effective hand hygiene, to prevent the transmission of bacteria, germs and infections. All staff will use the hand hygiene techniques, as set forth in the procedure. Using antimicrobial and/or non-antimicrobial soap and water, Dry hand with a clean towel. Turn off faucets with used paper towel and discard. Use new paper towel to open any exit doors and then discard.

2. On observation of 10/25/2022, between approximately 9:03 am, and 10:59 am, with A1 (Director of Quality, Risk, Compliance) and A4 (Director of Nursing) the following was observed. There were no paper towel and towel in the patient bathroom sink area 106, 108, 109, 205, 206 and 207 rooms. There were no paper towel located at the sink in the common area designated as dining area on the units 100 and 200.

3. On interview on 10/25/2025, at approximately 10:30 AM, with A4 confirmed the items found above on observation from 9:03 am, through 10:59 am.