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Based on observation, the facility failed to ensure magnetic locking doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101, 2012 Edition, Section 7.2.1.6.2. This deficiency affects 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 11:45 a.m., the corridor leading to the swing bed side from the hospital side was inspected. There was an exit sign directing egress through the horizontal exit into the swing bed side. There was a "push to exit" button which is secondary to a sensor allowing egress to approaching evacuees.

Based on observations, the facility failed to ensure corridor doors with automatic self closing devices were held open with a compliant device in accordance with NFPA 101, 2012 Edition, Section 19.2.2.2.7. These deficiencies affect 1 of 1 basement smoke compartment.

Findings include:

1. During an observation on 4/25/17 at 9:30 a.m., the basement clean linen room was inspected. There was a self-closer on the door, and the door was being held open with a chock.

2. During an observation 4/25/17 at 12:55 p.m., the central supply area was inspected. The room was over 50 square feet, it contained an office area, an area used for storage, and had an open room off of it used for storage which was also over 50 square feet. The door to the room was being held open by a kick-down device.

Based on observation, the facility failed to maintain corridor width in regards to projections into the corridor as allowed by NFPA 101, 2012 Edition, Section 19.2.3.4. This deficiency affects 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 10:08 a.m., the reception area at the main entry was inspected. There was a shelf under the reception window, it protruded into the corridor greater than six inches.

Based on observation, where the path of egress was not obvious, the facility failed to mark the path of egress by approved exit or directional exit signs in accordance with NFPA 101, 2012 Edition, Sections 7.10.1.2.2. This deficiency affects 2 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 11:45 a.m., the egress path leading toward the hospital side from the swing bed side was inspected. The route of egress was approved to go through the TV/family room in 1994. The visible exit sign was mounted on the ceiling past the door into the TV room, and appears to mark the exit as the door to the old hospital, which is a locked and keypadded door lacking any delayed egress.

Based on observation, the facility failed to ensure that all vertical openings were sealed in accordance with NFPA 101, 2012 Edition, Section 19.3.1.1. This deficiency affects 1 of 1 basement smoke compartment and 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 9:41 a.m., the server room was inspected. There was a vertical conduit for IT wires running up through the two hour separation to the floor above. The IT wires did not take up the entire conduit, which was stuffed with pink insulation. The space needed to be filled with a fire-stop material where it enters the ceiling and exits in the floor above.

Based on observation, the facility failed to ensure self-closing doors on hazardous areas were able to close and latch under the power of the self-closing hinges in accordance with NFPA 101, 2012 Edition, Section 19.3.2.1 and 19.3.2.1.3. These deficiencies affect 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 11:05 a.m., the swing bed side, supplies and equipment room was inspected. The room used to be a resident room, was over 50 square feet, and lacked a corridor door self-closer device.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). This deficiency affects 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 10:45 a.m., the swing bed side soiled linen room was inspected. There was an alcohol-based handrub station mounted over the light switch in the room.

Based on observations, the facility failed to ensure positioning of sprinklers to avoid obstructions in accordance with NFPA 13, 2010 Edition, Table 8.6.5.1.2, failed to install a sprinkler head in the dumbwaiter motor closet in accordance with NFPA 101, 2012 Edition, Section 19.3.5.1, and did not have fire suppression sprinklers under the basement crawl area per NFPA 101, 2012 Edition, Section 19.1.6.1 and Table 19.1.6.1. These deficiencies affect 1 of 1 basement smoke compartment.

Findings include:

1. During an observation on 4/25/17 at 9:20 a.m., the central supply room was inspected. There were two sprinkler heads obstructed by ceiling mounted heaters. The sprinklers were within 12 inches of the heaters and the heaters were lower than the deflector of the heads.

2. During an observation on 4/25/17 at 9:40 a.m., the dumbwaiter closet was inspected. The motor for the dumbwaiter was inside the closet. The closet lacked a sprinkler head.

3. After review of previous survey reports and a discussion with the maintenance supervisor on 4/25/17, the crawl space under the South Wing of the original hospital building was observed on 4/25/17 and it is not sprinklered as required by NFPA 101 for Type V (111) construction. This crawl space is viewed as a concealed combustible space since the wood floor joists and wood deck are exposed. Although sprinkler mains run through this crawl space, sprinkler heads were not installed.

Based on observation, the facility failed to maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1. This deficiency affects 1 of 1 basement smoke compartment.

Findings include:

1. During an observation on 4/25/17 at 9:20 a.m., the central supply room was inspected. There was medical storage of combustible material stacked within a foot of the sprinkler head above the storage. At least an 18 inch distance must be maintained.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. These deficiencies affect 1 of 1 basement smoke compartment and 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 9:35 a.m., the maintenance office was inspected. The portable fire extinguisher in the room was mounted 76 inches to the top of the handle. The maximum height is 60 inches.

2. During an observation on 4/25/17 at 10:15 a.m., the x-ray room was inspected. The portable extinguisher in the room was mounted 75 inches to the top of the handle.

Based on observation and interview, the facility failed to ensure power strips complied with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-Life Safety Code (LSC). This deficiency effects 2 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 10:01 a.m., the dental office was inspected. There was a multiplug adapter mounted to the outlet on the wall. There was no indication it was compliant with Underwriter's Laboratories (UL) 1363 standards.

In an interview on 4/25/17 at 10:01 a.m., staff member A stated he didn't know of any paperwork for the adapter.

2. During an observation on 4/25/17 at 10:31 a.m., the emergency room was inspected. There was a refrigerator plugged into a power strip. The power strip was not UL 1363 compliant.

Based on observation, the facility failed to store oxygen cylinders in from tipping over per NFPA 99, 2012 Edition, Sections 11.6.2.3. The deficiency affects 1 of 4 main level smoke compartments.

Findings include:

1. During an observation on 4/25/17 at 10:30 a.m., the ER empty tank storage area was inspected. There were 3 empty tanks sitting on the floor unrestrained.