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Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.1. This deficiency affects 1 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 11:57 a.m., the east exit by labor and delivery was inspected. The exit corridor consisted of a set of double doors which were blocked by two pieces of wheeled equipment which completely blocked the right most exit door. Exit discharges which are designed with two exit doors must keep both exit doors available for full and instant use. The exit corridor was not free and clear of all obstructions/stored equipment.

Based on observations, the facility failed to ensure fire rated doors with automatic self closing devices in the egress corridors on hold open mechanism closed completely when released from the hold open device in accordance with NFPA 101, 2012 Edition, Section 7.2.1.8.2 (1). These deficiencies affect 4 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 11:35 a.m., the 1-hour fire rated cross-corridor doors between the emergency department and the intensive care department were exercised. The doors failed to latch as one of the door catch devices was worn out and needed replaced rendering the doors less than smoke tight.

2. During an observation on 3/7/17 at noon, the 1-hour fire rated cross-corridor doors near pharmacy were exercised. The south most door failed to latch and bounced against the frame. The set of doors were numbered G-127.

Based on observation, the facility failed to maintain an exit discharge free and clear for immediate use in the case of an emergency in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.1 and Sections 7.1.6.2-3 and 7.2.1.2.1.1 (4). The deficiency affects 1 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 7:40 a.m., the south exit discharge door near the physician's library was exercised. The door failed to open to a full 90 degrees as the closing device limited the door opening to about 60 degrees of being fully open. It was confirmed with staff member B that a large wheel chair could not be pushed through the opening. Also, a towel had been wadded up and put at the base of the door to keep snow from blowing in. The towel could become a tripping hazard at this exit as it inhabited the walking surface in the means of egress.

Based on observations, the facility failed to fill penetrations in smoke/fire walls in accordance with NFPA 101, 2012 Edition, Section 8.3.5.1. The deficiency affects 5 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 2:20 p.m., the fire wall between radiology and the kitchen was inspected. There was one penetration where communication wiring went through the north wall which was not properly sealed.

2. During an observation on 3/7/17 at 2:35 p.m., the 1-hour fire wall at materials management was inspected. There were two heat pipes which were no longer sealed as the calking had shrunk exposing penetrations in the wall.

3. During an observation on 3/7/17 at 2:45 p.m., the 1-hour fire wall next to the clinic was inspected. There were two heat pipes which were no longer sealed as the calking had shrunk exposing penetrations through the wall.

4. During an observation on 3/7/17 at 3:00 p.m., the enclosed return air plenum area above the ceiling at the hard lid and orthopedics was inspected. There were three penetrations in the plenum which were not properly sealed.

5. During an observation on 3/7/17 at 3:20 p.m., the 2-hour fire wall which borders the kitchen was inspected. There was one open penetration where a roof drain comes down through the plenum. The plenum is not sprinkled by the automatic sprinkler system and must be sealed.

Based on observation, a portable fire extinguisher in the receiving area was not accessible in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. The deficiency could affect 1 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 9:40 a.m., the portable fire extinguisher in the receiving department was inspected. The extinguisher was obstructed by a table and was not available for immediate use unless first moving equipment.

Based on record review, the facility failed to conduct fire drills quarterly on each shift in accordance with NFPA 101 Life Safety Code, 2012 Edition, Section 19.7.1.6. The deficiency could affect 12 of 12 smoke compartments and all staff, patients and visitors.

Findings include:

1. Review of the facilities 2016-17 fire drill record showed that a fire drill was missing for the day shift for the fourth quarter of 2016.

Based on observation, the bulk oxygen storage tank located outdoors did not have a readable sign to indicate that there should be no smoking near the location of the tank in accordance with NFPA 99 Health Care Facilities Code, Section 11.3.4.1. The deficiency could affect 8 of 12 smoke compartments.

Findings include:

1. During an observation on 3/6/17 at 4:45 p.m., the out door bulk oxygen tank was inspected. The sign on the tank had completely bleached out and was no longer readable from a distance of five feet. The sign was not located on the gate to the enclosure, but on the tank itself which was obscured by the fencing material.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). The deficiencies affect 2 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 10:40 a.m., the electrical room near the kitchen was inspected. A ladder blocked access to the electrical panels in the room as it was leaned directly up against the front of the panels.

2. During an observation on 3/7/17 at 11:45 a.m., the electrical room in the intensive care unit was inspected. A ladder blocked access to the electrical panels in the room as it was leaned directly up against the front of the panels.

Based on observation, the facility failed to ensure electrical equipment complied with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14. This deficiency affects 1 of 12 smoke compartments.

Findings include:

1. During an observation on 3/7/17 at 10:00 a.m., the surgery staff lounge was inspected. The microwave oven was plugged into a power strip.

Based on observation, the facility failed to install electrical outlets in the medical gas store room in accordance with NFPA 99 Health Care Facilities Code, 2012 Edition, Section 5.1.3.3.2 (10). The deficiency affects 1 of 12 smoke compartments.

Findings include:

1. During an observation on 3/6/17 at 4:30 p.m., the medical gas store room was inspected. An electrical outlet located beside the walk-in-door was was not protected to prevent damage to the device. There were K size cylinders within four inches of the electrical outlet.