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Based on observation, the facility failed to provide for two exits from the basement of the Critical Access Hospital in accordance with NFPA 101 Life Safety Code, 2012 Edition, Section 19.2.4.2.

Findings include:

1. During an observation on 9/17/24 at 10:00 a.m., the basement was inspected. The basement is being used as a large storage area and includes a couple of seperate rooms. There is only one exit out of the basement. Code requires two exits from every story.

Based on observation, suite separation was not being maintained because the gap between the double doors closing off the suite from the corridor was too large, per NFPA 101, 2012 Edition, Section 19.2.5.7.1.2.

Findings include:

1. During an observation on 9/17/24 at 10:16 a.m., the cross-corridor smoke barrier doors on each end of the OB suite were found to have gaps exceeding the maximum allowable gap of 1/8" between the doors.

Based on an observation, the facility failed to assure hazardous rooms/areas had doors which were able to close and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3 and 19.3.2.1.5 (7) (7).

Findings include:

1. During an observation on 9/17/24 at 9:48 a.m., the purchasing area was inspected. The room exceeds 50 square feet, and contained a large amount of combustible supplies for the hospital. The corridor door did not have the required self-closer attached.

2. During an observation on 9/17/24 at 10:28 a.m., room 114 was found to be used to store equipment. The room exceeds 50 square feet and lacked the required self-closing device.

Based on observation, the facility failed to maintain all fire alarm systems in accordance with the standards of NFPA 72-2010, Section 10.5.5.2.1 - 10.5.5.2.4.

Findings include:

1. During an observation on 9/17/24 at 10:10 a.m., the fire alarm control panel (FACP) was inspected. The location of the electrical panel and breaker serving the FACP were not identified on the FACP. The Surveyor was unable to locate the panel and breaker serving the FACP.

Based on observation, the facility failed to ensure sprinkler piping was free from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.; and failed to maintain escutcheon plates around sprinkler heads in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.1.; and failed to replace or test sprinkler gauges every 5 years in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2,

Findings include:

1. During an observation on 9/17/24 at 9:42 a.m., the outside biohazard room was inspected. There was a cat 5 wire running to a security camera outside the room, the bundle of wire was secured to the sprinkler pipe in the room.

2. During an observation on 9/17/24 at 10:20 a.m., the ER trauma room was inspected. There was a sprinkler head in the room which looked like it had been displaced. It was not perpendicular to the floor and the escutcheon plate had fallen down, leaving an annular opening around the sprinkler pipe.

3. During an observation on 9/17/24 at 10:40 a.m., the standpipe was inspected. The gauge on the standpipe was found to have an installation date of 7/2019 written on it. Gauges are to be tested or replaced every 5 years.

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.

Findings include:

1. During an observation on 9/17/24 at 9:51 a.m., the portable extinguisher on the wall in the boiler room hall was inspected. The extinguisher was mounted 67 inches high. Maximum allowable height is 60 inches from floor to top of extinguisher.

Based on observations, the facility failed to maintain electrical panels to be locked where the circuit breakers going to category 1 and 2 rooms may be accessed by unauthorized building occupants per NFPA 99 Health Care Facilities Code, 2012 Edition, Sections 1.3.2.3, and 6.3.2.2.1.3(A), and NFPA 70 National Electrical Code 2011, Section 110.26(F).

Findings include:

1. During an observation on 9/17/24 at 10:24 a.m., circuit breaker panels with breakers identified to be supplying rooms in the ER were located in the corridor system. The panels were found to be unlocked and accessible by anyone in the facility.