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Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Facilities Director, one area contained items that were obstructing the clear width of the egress path. The areas that were in non compliance were:
1) Emergency Department waiting room area in which a standing hygeine cart, a bookshelf, and a trash can were stored within the means of egress
2) Storage of stairs for "therapy" in corridor outside room #220
Note: Deficiency #2 was corected during the survey

This deficiency potentially effected 2 of 6 smoke compartments.

Through record review, observation, and testing during the survey, May 15 and 16, 2018, it was determined that the facility failed to maintain the emergency lighting systems.

During the review of the facility ' s records, staff could not provide documentation indicating that the annual 1-1/2-hour (90 minute) test of the battery operated emergency lighting occured.
Per 2012 Edition NFPA 101 section 7.9.3.1.1(3)

This deficiency potentially effected all staff and all residents in areas in which the battery back up lights are located throughout the facility.

Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to maintain the ceiling tiles in IT closets and staff areas as required.
 
During the walk through of the facility, with the Facility Director, it was found that ceiling tiles were missing in three (3) areas which caused a lack of a smoke partition to hold the heat in the area to effectively utilize the sprinkler system or if the ceiling tiles were not placed had ineffective or incurretly spaced sprinkler protection. The areas in non-compliance were:
1) ED staff lounge which had two (2) holes in the ceiling tiles that were two inches (2") in diameter.
2) Two (2) IT closets on the second floor
Per NFPA 13 (2010 Edition), section 8.1.1

These deficiencies effected 3 smoke compartments of 6.

Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to maintain the hazardous areas.
 
During the walk-through of the facility, with the Facility Director, it was found that the mechanical room contained an unsealed wire penetration in the one-hour fire rated wall to the corridor.

This deficiency effected 1 of 6 smoke compartments.

Through observation during the survey,May 15 and 16, 2018, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.
 
During the walkthrough of the facility, with the Facility Director, alcohol based hand rub dispensers (ABHR) were located above an electrical outlets or light switches. Two (2) areas in non-compliance were:
1) Birthing suite area by the nurse station
2) Outpatient infusion area.

These deficiencies effected 2 out of 6 smoke compartments.

Through observation during the survey, My 15 and 16, 2018, it was determined that the facility failed to install the smoke detectors as required.

During the walk through of the facility, with the Facilities Director, it was determined that smoke detectors were located within three feet (3') of HVAC intake or return plenums in the following areas:
1) In mammography room
2) Outside of x-ray room nurse station
3) In nurse station work room at Med Surgery
4) In nurse station at surgery check in
Per NFPA 72 (2010 Edition), section 17.7.4.1

Tese deficiencies effected 3 of 6 smoke compartments.

Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to provide smoke detectors in all areas that are open to the corridor.

During the walk through of the facility, with the Facility Director,the Emergency Department registration area contained spaces in which were open to the corridor. The office spaces in the registration area contained no smoke detection.

This deficiency effected 1 smoke compartment out of 6.

Through observation during the survey,May 15 and 16, 2018, it was determined the facility failed to inspect the automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Facilities Director, the facility failed to inspect the automatic sprinkler system gauges on a monthly basis between January 2018 and April 2018.
Per 2011 Edition of NFPA 25, section 5.2.4.1

This deficiency potentially effected all staff and residents within the facility.

Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to maintain the doors to the corridor.
 
During the walk through of the facility, with the Facilities Director, the door to the radiology room contained tape on the door latching device, prohibiting the door from latching into the frame.
Note: Tape was removed from the door during the survey.

This deficiency potentially effected 1 smoke compartment, 3 staff, and 2 patients.

Through record review and discussions with the staff during the survey, May 15 and 16, 2018, it was determined that the facility failed to have all elements of the emergency plan in place.

During the review of the facility records, with the Facilities Director, the facility failed to show the following items in the emergency fire plan:
1) That staff was calling 911
2) That evacuation of the smoke compartment was occuring
3) That evacuation of the immediate fire area was occuring.
Per NFPA 101, section 19.7.2.2

This deficiency potentially effected all staff and residents within the facility.

Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Facilities Director, extension CORDS were being utilized to power equipment in the following areas:
1) Utilized in file storage room
2) In X-ray room control area
3) One extension cord in nurse office
Note: All deficiencies were corrected during the survey.
Per NFPA 70, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ").

Tese deficiencies effected 2 out of 3 smoke compartments within the facility.

Through observation during the survey, May 15 and 16, 2018, it was determined that the facility failed to install electrical outlets in accordance with NFPA 99 in the outdoor oxygen storage cage.
 
During the walk through of the facility, with theFacility Manager, the oxygen storage cage, for the ambulance service, contained an electrical outlet installed at forty-two inches (42") off of the ground. The cage contained four (4) "H" size oxygen cyliners for storage and the electrical device was located adjacent to an "H" tank.
Per NFPA 99, 2012 Edition, section 5.1.3.3.2(5) must meet the requirements of NFPA 70. Which states that the electrical device must be located in an area where damage to the device will not occur if a tank tips over.

This deficiency occured outside of the facility and in one area of the building.