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Based upon observation and staff interview the facility fails to maintain proper separation/protection of designated hazard space. Conditions observed could allow the spread of fire/smoke to areas of the facility occupied by patient/patient care operations, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During the survey tour conducted on Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] Physical Therapy storage room is identified as one-hour fire separated, however, construction is not complete. Large hole to room to east in upper part of room, missing penetration seals.

2.] Construction area at west end of building complex, not properly separated from occupied/operational areas of the hospital. Non-fire retardant, Plywood was observed being used as temporary wall.

Facility staff P was present and is aware of the findings.

NFPA 101-2000, section 19.3.2.1[7] and 8.4.1: for item 1 above; separation of storage area specified at one hour construction.

NFPA 101-2000, section 19.1.1.4 and 4.6.10: for item 2 above; occupancy of building during construction activity with life safety measures as approved by authority having jurisdiction. Fire/smoke separation is expected by local and state AHJ. Architect is to specify minimum expectations for fire/smoke separation of construction area to occupied portions of the existing building.

Based upon observation and staff interview the facility failed to maintain emergency exit lighting as required. Required, generator powered emergency lighting in critical areas, such as medication rooms, may not be placed in off position by operation of switch. This deficiency affects 1 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a total capacity of 35 and a census of 25 at the time of survey.

Findings include:

During the facility tour on Monday, May 2, 2011, between 1 PM and 4 PM the following conditions were identified:

1.] The new medication room in the surgical suite was provided with switch to allow the emergency lighting to be turned off.

Facility staff P was also present and is aware of this finding. Item was corrected prior to inspector leaving facility.

NFPA 101-2000 requires; Emergency lighting of at least 1? hour duration is provided in accordance with 7.9. 19.2.9.1. 30 second monthly operability test is to be conducted and documented. Annual 90 minute operability/battery test is to be conducted and documented.

Based upon observation, records review and staff interview the facility failed to properly install required fire detection and alarm equipment in accordance with NFPA 72 requirements. This deficient practice fails to ensure that all occupants will be properly notified in the event of an emegency, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During the facility inspection tour on Monday, May 2, 2011, between 1 PM and 4 PM, and Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] No alarm notification device provided in West Courtyard.

2.] No alarm notification device provided in Healing Garden Courtyard area.

3.] Data Room 1 smoke detector is more than 12 inches below ceiling

4.] Emergency Electrical Entry room heat detector is more than 12 inches below ceiling.

Facility staff P was also present and is aware of these findings. Items 2 through 3 appear to be construction completion items from new construction now being accepted and placed into service.

A review of applicable NFPA documents reveals: A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. 19.3.4. 9.6

Based upon observation, records review and staff interview the facility failed to properly maintain the fire sprinkler system as required by NFPA 25 and NFPA 13 requirements. This deficient practice can adversely affect the operation of the sprinkler heads, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During The facility tour on Monday, May 2, 2011, between 1 PM and 4 PM the following conditions were identified:

1.] Escutcheon ring missing from sidewall head in bathroom to east of cafeteria.

2.] Tiles out in foyer area at south exit for new surgical suite.

Facility representative P was also present and was made aware of these findings. Both of these items were corrected prior to inspector leaving facility.

This finding is supported by the following NFPA code reference: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13-1998, NFPA 25-1998, NFPA 101-2000, section 9.7.5

Based upon observation, records review and staff interview the facility failed to maintain compliance with the written smoking policy. Facility is a non-smoking facility per policy and failing to enforce the policy could result in a fire, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During the inspection tour on Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] Evidence of smoking found in West Courtyard at trash can.

2.] Evidence of smoking found in the Healing Garden Courtyard.

Facility Staff P was also present and is aware of these findings.

Record review of the following NFPA standard requires: Smoking regulations shall be adopted.................... NFPA 101-2000, section 19.7.4; see also written procedure of facility.

Based upon observation, records review and staff interview the facility failed to provide proper inspection and cleaning of plenum and fan of the kitchen hood. Failure to inspect/clean ductwork and fan can lead to fire conditions inside of the plenum ductwork, affecting 1 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of the survey.

Findings include:

During the facility tour and records review on Monday, May 2, 2011, between 1 PM and 4 PM the following conditions were identified:

1.] Documentation of semi-annual duct and fan inspection/cleaning was not provided. Last documented in 2009

Facility staff P was also present and is aware of this condition.

A review of applicable codes reveals: Cooking facilities are protected in accordance with NFPA 101-2000 sections 9.2.3. & 19.3.2.6, NFPA 96 requires that the ventilation hood, ductwork and fan motor/blades be free of grease accumulations.

Based upon observation and staff interview the facility failed to maintain Liquefied Petroleum storage facility as required by NFPA 58, affecting 1 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at the time of survey.

Findings include:

During the facility tour on Tuesday, May 3, 2011, between 9 AM and 4 PM the following condition was identified:

1.] Carbon steel piping at the Liquefied Propane storage facility for auxiliary boiler fuel is in need of corrosion protection [paint or primer].

Facility staff P was also present and is aware of this finding.

NFPA standard: NFPA 58 as adopted by State of Kansas, requires piping at storage facility to be protected against corrosion.

Based upon observation and staff interview the facility failed to maintain electrical installations as
prescribed by NFPA 70. This deficient practice could cause an electrial failure or fire. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at the time of survey.

Findings include:

During the facility tour on Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] Temporary nurses' station - power strip to power strip use observed

2.] Main laboratory - power strip to power strip use observed

Facility staff P was present and is aware of this finding.

Review of applicable NFPA documentation: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. See NFPA 101-2000, section 9.1.2

Based upon observation and staff interview the facility fails to maintain proper separation/protection of designated hazard space. Conditions observed could allow the spread of fire/smoke to areas of the facility occupied by patient/patient care operations, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During the survey tour conducted on Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] Physical Therapy storage room is identified as one-hour fire separated, however, construction is not complete. Large hole to room to east in upper part of room, missing penetration seals.

2.] Construction area at west end of building complex, not properly separated from occupied/operational areas of the hospital. Non-fire retardant, Plywood was observed being used as temporary wall.

Facility staff P was present and is aware of the findings.

NFPA 101-2000, section 19.3.2.1[7] and 8.4.1: for item 1 above; separation of storage area specified at one hour construction.

NFPA 101-2000, section 19.1.1.4 and 4.6.10: for item 2 above; occupancy of building during construction activity with life safety measures as approved by authority having jurisdiction. Fire/smoke separation is expected by local and state AHJ. Architect is to specify minimum expectations for fire/smoke separation of construction area to occupied portions of the existing building.

Based upon observation and staff interview the facility failed to maintain emergency exit lighting as required. Required, generator powered emergency lighting in critical areas, such as medication rooms, may not be placed in off position by operation of switch. This deficiency affects 1 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a total capacity of 35 and a census of 25 at the time of survey.

Findings include:

During the facility tour on Monday, May 2, 2011, between 1 PM and 4 PM the following conditions were identified:

1.] The new medication room in the surgical suite was provided with switch to allow the emergency lighting to be turned off.

Facility staff P was also present and is aware of this finding. Item was corrected prior to inspector leaving facility.

NFPA 101-2000 requires; Emergency lighting of at least 1? hour duration is provided in accordance with 7.9. 19.2.9.1. 30 second monthly operability test is to be conducted and documented. Annual 90 minute operability/battery test is to be conducted and documented.

Based upon observation, records review and staff interview the facility failed to properly install required fire detection and alarm equipment in accordance with NFPA 72 requirements. This deficient practice fails to ensure that all occupants will be properly notified in the event of an emegency, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During the facility inspection tour on Monday, May 2, 2011, between 1 PM and 4 PM, and Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] No alarm notification device provided in West Courtyard.

2.] No alarm notification device provided in Healing Garden Courtyard area.

3.] Data Room 1 smoke detector is more than 12 inches below ceiling

4.] Emergency Electrical Entry room heat detector is more than 12 inches below ceiling.

Facility staff P was also present and is aware of these findings. Items 2 through 3 appear to be construction completion items from new construction now being accepted and placed into service.

A review of applicable NFPA documents reveals: A fire alarm system with approved components, devices or equipment is installed according to NFPA 72, National Fire Alarm Code, to provide effective warning of fire in any part of the building. 19.3.4. 9.6

Based upon observation, records review and staff interview the facility failed to properly maintain the fire sprinkler system as required by NFPA 25 and NFPA 13 requirements. This deficient practice can adversely affect the operation of the sprinkler heads, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During The facility tour on Monday, May 2, 2011, between 1 PM and 4 PM the following conditions were identified:

1.] Escutcheon ring missing from sidewall head in bathroom to east of cafeteria.

2.] Tiles out in foyer area at south exit for new surgical suite.

Facility representative P was also present and was made aware of these findings. Both of these items were corrected prior to inspector leaving facility.

This finding is supported by the following NFPA code reference: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13-1998, NFPA 25-1998, NFPA 101-2000, section 9.7.5

Based upon observation, records review and staff interview the facility failed to maintain compliance with the written smoking policy. Facility is a non-smoking facility per policy and failing to enforce the policy could result in a fire, affecting 2 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of survey.

Findings include:

During the inspection tour on Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] Evidence of smoking found in West Courtyard at trash can.

2.] Evidence of smoking found in the Healing Garden Courtyard.

Facility Staff P was also present and is aware of these findings.

Record review of the following NFPA standard requires: Smoking regulations shall be adopted.................... NFPA 101-2000, section 19.7.4; see also written procedure of facility.

Based upon observation, records review and staff interview the facility failed to provide proper inspection and cleaning of plenum and fan of the kitchen hood. Failure to inspect/clean ductwork and fan can lead to fire conditions inside of the plenum ductwork, affecting 1 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at time of the survey.

Findings include:

During the facility tour and records review on Monday, May 2, 2011, between 1 PM and 4 PM the following conditions were identified:

1.] Documentation of semi-annual duct and fan inspection/cleaning was not provided. Last documented in 2009

Facility staff P was also present and is aware of this condition.

A review of applicable codes reveals: Cooking facilities are protected in accordance with NFPA 101-2000 sections 9.2.3. & 19.3.2.6, NFPA 96 requires that the ventilation hood, ductwork and fan motor/blades be free of grease accumulations.

Based upon observation and staff interview the facility failed to maintain Liquefied Petroleum storage facility as required by NFPA 58, affecting 1 of 2 smoke zones. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at the time of survey.

Findings include:

During the facility tour on Tuesday, May 3, 2011, between 9 AM and 4 PM the following condition was identified:

1.] Carbon steel piping at the Liquefied Propane storage facility for auxiliary boiler fuel is in need of corrosion protection [paint or primer].

Facility staff P was also present and is aware of this finding.

NFPA standard: NFPA 58 as adopted by State of Kansas, requires piping at storage facility to be protected against corrosion.

Based upon observation and staff interview the facility failed to maintain electrical installations as
prescribed by NFPA 70. This deficient practice could cause an electrial failure or fire. Facility is a 25 bed critical access hospital with a 10 bed Distinct Patient Unit. This facility has a capacity of 35 and a census of 25 at the time of survey.

Findings include:

During the facility tour on Tuesday, May 3, 2011, between 9 AM and 4 PM the following conditions were identified:

1.] Temporary nurses' station - power strip to power strip use observed

2.] Main laboratory - power strip to power strip use observed

Facility staff P was present and is aware of this finding.

Review of applicable NFPA documentation: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. See NFPA 101-2000, section 9.1.2