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Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions or restricted doors, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 15 of 15 residents in the facility.

Findings:

During the facility tour on 1/20/22, between the hours of 9:00a-4:00p observation revealed the corridor between the OR and recovery suites is being used for storage. Also the corridor at the south stair 1st floor by elevator is being used for storage.
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Interview with the Director of Facility Management revealed the facility was not aware that the exit in the corridor was obstructed.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10. Fire extinguishers are available to extinguish small fire or smoke emergencies. This deficient practice could potentially affect 15 of 15 residents.

Findings:

During the facility tour and the record review on 1/20/22, between the hours of 9:00a-4:00p observation and record review revealed the fire extinguishers were last inspected by AAA Safety on 6/30/20.

Interview with the Director of Facility Management revealed the facility was not aware that the annual inspection on the fire extinguishers had not been conducted.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke and fire from one compartment to the other in the facility. The deficient practice had the potential to affect 15 of 15 patients.

Findings:

During the facility tour on 1/20/22 between the hours of 9:00a to 4:00p observation revealed penetrations in the OR East barrier, 3 North, & 3 South.

Interview with the Director of Facilities Management revealed the facility was not aware of the unsealed penetrations.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 15 of 15 residents.

Findings:

During the facility tour on 1/20/22, between the hours of 9:00a-4:00p observation revealed barrier door of 2nd floor consultation is not rated and is not self closing. Center corridor barrier door does not self close and latch.

Interview with the Director of Facilities Management revealed the facility was not aware of the cross corridor doors were not creating a smoke resistive seal when closed.