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Based on observations made on October 25, and 26, 2010, the facility failed to maintain the two-hour fire resistance rating of a fire barrier.

The findings include:

In accordance with Section 19.1.2.3 of NFPA 101, LSC, 2000 Edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

1. The Networking Room on the CAH was observed at 3:22 p.m. on 10/25/2010. The floor conduit, which links the Old Nursing Home with the Networking Room in the CAH, was not sealed.

2. The two hour fire barrier wall between the Clinic Hall and the CAH was observed at 7:40 a.m. on 10/26/2010. A hole had been drilled in the wall near the ceiling, over the one and one half hour rated door, for communication wiring and was not sealed properly.

Based on observations made on October 25 and 26, 2010 the facility failed to maintain the fire and smoke resistance rating of ceiling assemblies in a building of Type II (211) construction.

The findings include:

In accordance with Section 19.1.6.1 of NFPA 101, 2000 Edition; building construction type and height shall meet one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

1. The Oxygen Storeroom (Old Incinerator Room) near the Old Kitchen was observed at 11:22 a.m. on 10/25/2010. The ceiling was damaged from a roof leak along a drywall seam. A two foot by six inch area required mud and tape to seal the hole.

2. The Dark Room in Radiology was observed at 2:00 p.m. on 10/25/2010. One ceiling tile had a four inch hole in it where a duct had been removed and a new tile had not been installed.

Based on observations which were made on October 25 and 26, 2010, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 Edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

Findings include:

1. The east wall of the Oxygen Store Room (Old Incinerator Room), was observed at 11:24 a.m. on 10/25/2010. There was a hole in the east wall where a telephone cord had been removed and not sealed.

2. The Registration Office was observed at 3:11 p.m. on 10/25/2010. The overhead fire doors separating the Registration Office from the main entryway and corridor were blocked from closing by a fan and basket.

Based on observations and interviews of maintenance staff made on October 25 and 26, 2010, the facility failed to assure that there were no impediments to closing and latching corridor doors.

In accordance with section 19.6.6.3.3 of NFPA 101, 2000 edition; doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

The findings include:

1. The Out of Town Registration Office was observed at 2:30 p.m. on 10/25/2010. The corridor door to this room was blocked open with a wedge.

2. The corridor door to the Old Kitchen hall was exercised at 7:00 a.m. on 10/26/2010. This door did not latch as the lock set had been removed.

Interview with maintenance staff at this same time revealed that the lock set had been removed to ease cart passage, as meals come from the new Long Term Care Center by cart to the patient rooms in the CAH through this door three times daily.

Based on observations made on October 25, 2010, it was determined that not all fire doors in fire walls are equipped with self closing devices which would allow such doors to be capable of closing to positive latching.

Findings include:

In accordance with Section 19.2.2.2.6 of the Life Safety Code (LSC), 2000 Edition; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure is held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of:

a) the required manual fire alarm system;

b) local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and

c) the automatic sprinkler system, if installed.

The fire rated door to the Mechanical Room was observed at 11:05 a.m. on 10/25/2010. This door is at the bottom of the stairway enclosure and is the only door separating the mechanical room from the exit corridor. The door was rated one and one half hours, but the door was not self-closing.

Based on observations made on October 25 and 26, 2010; the facility failed to assure that doors opening into enclosed courtyards were properly identified as not being an exit way.

The findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per the 2000 Edition of NFPA 101 Section 7.10.8.1 Marking of Means of Egress.

The employee break room was observed at 12:40 p.m. on 10/25/2010. There was an exit sign placed over the door which enters the enclosed courtyard. On a previous survey, the courtyard was not fully enclosed until the new nursing home was built and one side of the home enclosed the courtyard. The exit sign should be removed and signed added that states "NO Exit".

Based on observations made on October 25 and 26, 2010, the facility failed to maintain or establish the fire rated protection for hazardous areas.

The findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

1. The exit corridor by the Old Kitchen was observed at 10:50 a.m. on 10/25/2010. The west wall of the Boiler Room where a three foot by four foot exhaust duct passes through the wall just above the exit corridor was observed. The exhaust duct was not sealed properly where a tin plate had been installed over the penetration.

2. The Old Kitchen dry goods storeroom was observed at 11:05 a.m. on 10/25/2010. The storeroom door was tied back with a Bunge cord.

3. The Patient Account Managers Office was observed at 3:25 p.m. on 10/25/2010. A door between this office and the Medical Records storeroom was observed to be open and without a self-closing device. All doors to storerooms/hazardous areas must be self-closing.

4. The Medical Records storeroom was observed at 3:26 p.m. on 10/25/2010. The pair of corridor doors to this office were without self-closing devices.

Based on observations and review of the previous facility history notes on October 25 and 26, 2010, the facility failed to provide for hard surface paths and safe surfaces from exit discharges to the public way and the facility failed to assure that numbers posted at a lock for a door in a means of egress were displayed and identifiable.

In accordance with Section 7.7.1 of NFPA 101, LSC and interpretations from CMS; there shall be provided a hard surface path from the exit discharge to the public way or area of refuge in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces.

Findings include:

The east exit door to the CAH was examined at 2:40 p.m. on 10/25/2010. There was no hard path surface to the public way at this exit as the concrete only extended about twelve feet beyond the exit door. A hill was straight ahead to the east and the same was to the south. Easiest access to the public way might be to the north around the building.

Based on review of battery powered emergency light fixture testing logs on October 25 and 26, 2010, the facility did not ensure that the required 90-minute annual tests were conducted on all battery powered emergency light fixtures in the facility.

Findings include:

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The records were reviewed for the battery pack emergency lighting at 10:30 a.m. on 10/25/2010. The record indicated that the battery pack lighting had been maintained monthly and annually in 2009, and was due again in July of 2010. There was no record for the 90 minute annual inspection of the battery pack emergency lighting for July of 2010.

2. The battery pack emergency lighting in the Operating Room was checked at 1:40 p.m. on 10/25/2010. After testing the battery light system, the battery in this unit may be dead because the lights did not come on.

Based on observations made on October 26, 2010, the facility failed to maintain the continuous illumination for one exit sign.

Findings include:

In accordance with Sections 19.2.10.1 and 7.10.5.2 of NFPA 101, LSC, 2000 Edition; exit signs shall be continuously illuminated. Exit signs that are internally illuminated must meet UL 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

Exit signs in the CAH were reviewed at 10:00 a.m. on 10/26/2010. The exit sign on the north hall near the nurses' station was dark, as both bulbs were burned out.

Based on review of the fire drill reports received by facsimile on November 1, 2010, the facility failed to assure that fire drills were documented properly on each shift at least quarterly.

The findings include:

In accordance with NFPA 101 section 19.7.1.2, 2000 Edition; fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

The fire drill reports were reviewed on 11/1/2010. There are only day and night shifts. It was determined through review of the fire drill reports that documentation for a night fire drill that was conducted on 5/11/2010 was incomplete. The time the fire drill was conducted was not indicated on the report. Also, other drills which were conducted in 2009-10 had incomplete documentation, those included: The fire drill and inspection report dated 10/22/2010 did not contain a time; the fire drill and inspection report dated July 29, 2010 did not contain a time; the fire drill and inspection report dated 4/12/2010 did not contain a time; the fire drill and inspection report for 1/6/2010 did not contain which shift it was done for and was not signed by those participating during the drill; and the fire drill and inspection report dated 10/9/2009 did not include a time.

During an exit interview with facility staff at 10:30 a.m. on 10/26/2010; one Safety Committee attendee admitted that fire drills were not being conducted and documented for the night shift.

Based on observation made on October 25 and 26, 2010, the facility failed to ensure that the location of the dedicated power circuit branch servicing the fire alarm panel was permanently addressed on the alarm panel.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, (1999 edition); the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The FACP and connecting services were reviewed at 10:13 a.m. on 10/25/2010. The Simplex FACP located on the north wall of the Electrical room, indicated that electrical panel ES controlled fed the FACP, but breaker number 7 of panel ES was not identified in RED.

Based on observations made on October 25 and 26, 2010, the facility failed to assure that the automatic sprinkler system provided for complete coverage of all portions of the building.

The findings include:

In accordance with Section 5-6.3.3 (Minimum Distance from Walls) of NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition; sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

In accordance with Section 5-6.4.2 (Deflector Orientation) of NFPA 13; deflectors of sprinklers shall be aligned parallel to ceilings, roofs, or the incline of stairs.

The building is of Type II (211) construction which requires that all portions of the facility be protected by the automatic sprinkler system. The Medical Air Storeroom was examined at 10:12 a.m. on 10/25/2010. A sprinkler head was placed at the junction of the north wall and ceiling. The following are deficiencies related to the placement of the sprinkler head:
a) The spray pattern for this sprinkler head was obstructed by:
i) how close it was placed to the wall, and
ii) a pipe blocked the spray pattern.
b) The orientation of the deflector was not parallel with the ceiling.

Based on observations made on October 25, 2010, the facility failed to maintain the sprinkler system and its components in accordance with the standards of NFPA 13 and NFPA 25.

The findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 Edition.

In accordance with Section 2-2.1.1 of NFPA 25, 1998 Edition; sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

According to Annex 19.3.5.5 For the proper operation of sprinkler systems, cubicle curtains and sprinkler locations need to be coordinated. Improperly designed systems might obstruct the sprinkler spray from reaching the fire or might shield the heat from the sprinkler. Many options are available to the designer including, but not limited to, hanging the cubicle curtains 18 in. (46 cm) below the sprinkler deflector; using 1/2-in. (1.3-cm) diagonal mesh or a 70 percent open weave top panel that extends 18 in. (46 cm) below the sprinkler deflector; or designing the system to have a horizontal and minimum vertical distance that meets the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. The test data that forms the basis of the NFPA 13 requirements is from fire tests with sprinkler discharge that penetrated a single privacy curtain.

1. One escutcheon ring was missing on the south east corridor near the specialist office as observed at 2:35 p.m. on 10/25/2010.

2. Room 60 was reviewed on 10/25/2010 and the following deficiencies were noted:
a) One escutcheon ring was missing at 2:56 p.m. and
b) The privacy curtain was not one half inch mesh as observed at 2:58 p.m.

3. The escutcheon ring and sprinkler head were painted in room 45 as observed at 3:05 p.m. on 10/25/2010.

Based on observations and interview with Laboratory staff made on October 25 and 26, 2010, the facility failed to treat all furnishings with a fire retardant material.

Findings include:

The State Licensing and Certification Bureau Notice #101207 prohibits the use of wrapping paper or similar coverings to decorate the doors or wall surfaces during holiday seasons. Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant per Section 19.7.5.4 of the Life Safety Code. Hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of Sections 10.3.1 of 19.7.5.1 of the Life Safety Code.

The exit corridor near the Laboratory was observed at 1:55 p.m. on 10/25/2010. There were five wall hangings located on the corridor walls which were not treated with a flame retardant material. Also, in the entry way near the registration area, there was one wall hanging which was not treated.

An interview was conducted at this same time with Laboratory staff. She stated that families and residents had donated the wall hangings and they were hung to make the corridors and facility a more "homier" atmosphere. Laboratory staff did not realize that furnishings had to meet a flame spread requirement.

Based on observation made on October 25 and 26, 2010, the facility failed to provide documentation that all window coverings met the Standards of Section 10.3.1 of NFPA 13, for flame spread ratings.

Findings include:

In accordance with Section 19.7.5.1 of NFPA 101, 2000 edition; draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies.
Exception: Curtains at showers.

1. The Comfort Suite room was observed at 2:25 p.m. on 10/25/2010. The valance window topper in this room did not have a tag attesting that it had been treated with a flame retardant chemical.

2. Room 62 was observed at 2:41 p.m. on 10/25/2010, the green window valance had no tag attesting that it had been treated with a flame retardant chemical.

3. Room 56 was observed at 3:00 p.m. on 10/25/2010, the draperies in this room had no tag attesting that they had been treated with a flame retardant chemical.

4. Room 44 was observed at 3:07 p.m. on 10/25/2010, a plastic curtain was hung as a door to a bathroom.

5. The open area of the main entryway was observed at 3:10 p.m. on 10/25/2010, the vertical blinds in this room had no tag attesting that they had been treated with a flame retardant chemical.

6. The Patient Account Managers office was observed at 3:20 p.m. on 10/25/2010, the Woven Wood blinds in this office did not contain any tag attesting that they had been treated with a flame retardant chemical.

Based on observations made on October 25 and 26, 2009, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over.

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99 (1999 edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

1. The exterior door of the Medical Gas Storeroom was observed at 10:10 a.m. on 10/25/2010. This room had one nitrous tank which was not secured.

2. The Oxygen Storeroom near the Old Kitchen was observed at 11:10 a.m. on 10/25/2010. There were three empty cylinders stored with full cylinders in a wooden storage rack.

Based on observation made on October 25, 2010, the facility failed to keep a reserve tank hooked up for Nitrous Oxide in the medical gas store room.

Findings include:

In accordance with Section 4-3.1.1.5 of Chapter 4 (Gas and Vacuum Systems) of NFPA 99 (Standard for Health Care Facilities 1999 Edition; (a) A cylinder manifold shall have two banks (or units) of cylinders that alternately supply the piping system, each bank having a pressure regulator and cylinders connected to a common header. Each bank shall contain a minimum of two cylinders or at least an average day ' s supply unless normal delivery schedules require a greater supply. When the content of the primary bank is unable to supply the system, the secondary bank shall automatically operate to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover to the secondary bank occurs.
(b)A check valve shall be installed between each cylinder lead and the manifold header to prevent the loss of gas from the manifolded cylinders in the event the pressure relief device on an individual cylinder functions or a cylinder lead (pigtail) fails. The check valve shall be of a material suitable for the gases and pressures involved.

The Medical Gas Storeroom was observed at 10:30 a.m. on 10/25/2010. The surveyor noted that only one tank was connected to the Nitrous Oxide manifold. The manifold had two banks with master cylinders and access was there for a reserve cylinder which was not in place.

Based on observation on October 25, 2010, all anesthetizing locations shall be protected and labeled in accordance with NFPA 99, Standard for Health Care Facilities.

Findings include:

In accordance with Section 4-3.5.4.2 of Chapter 4 (Gas and Vacuum Systems) of NFPA 99 (Standard for Health Care Facilities) 1999 Edition; the shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

The vacuum and oxygen shut off valves on the medical gas system were observed at 2:10 p.m. on 10/25/2010. The valves on the north and south corridor walls were not labeled to reflect the rooms that they controlled and the gas which was being supplied. The vacuum sign was missing on the north corridor shut off location and both the vacuum and the oxygen signs were missing on the south corridor shut off location.

Based on observations made on October 25 and 26, 2010, the facility failed to post a "No Smoking" sign(s) within 50 feet of the helicopter landing pad.

The findings include:

No smoking shall be permitted within 50 feet of the helicopter landing pad edge per section 2-5 of NFPA 418, 1995 edition. "No Smoking" signs shall be erected at access/egress points to the landing pad.

The facility had a helicopter landing pad located on the ground level to the south of the building as observed at 11:25 a.m. on October 26, 2010. The required "No Smoking" sign(s) was not posted within 50 feet of the access/egress point to the landing pad.

Based on observations made on October 25 and 26, 2010, the facility failed to post a precautionary sign at a location where oxygen was being administered or ready for use.

The findings include:

In accordance to section 8-3.1.11.3 Signs of NFPA 99, 1999 Edition; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

1. The exterior door of the Medical Gas Storeroom was observed at 10:10 a.m. on 10/25/2010. There was no sign on the door telling one that it was a medical gas storeroom, nor was there a no smoking sign.

2. The exterior door to the Oxygen Storeroom was observed at 11:10 a.m. on 10/25/2010. There was no sign on the door telling one that it contained combustible gasses or oxygen.

Based on review of the emergency generator test reports and logs on October 25, 2010, the facility failed to assure that the emergency generator supplying power to the Operating Room (life support systems included) located within the confines of the Critical Access Hospital (CAH) building met NFPA 110 requirements for an annual load bank testing or equivalency.

The findings include:

Section 6-4.2 of NFPA 110 (1999 edition) requires that generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. In accordance with 6-4.2.2 of NFPA 110 natural gas generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually (load bank tested) with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of two continuous hours.

The Operating Room is located within the confines of the CAH building and has life support systems that are dependent upon the emergency generator meeting load bank test demands. The generator test reports and logs were reviewed at the facility on October 25, 2010. The generator monthly load tests were current including the fact that within the last twelve months the generator had been run for two continuous hours with the available EPSS load. There was no indication or specific documentation that all of the conditions for a load bank test per 6-4.2 or 6-4.2.2 of NFPA 110 had been met in 2008 , 2009 or thus far in 2010.

Based on observations made on October 25 and 26, 2010, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 edition, NFPA 99, 1999 edition and interpretations by the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords, including power strips or multiple adaptors, used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction. One means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 Edition and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 Edition. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

In accordance with 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

1. The Central Supply office was observed at 1:33 p.m. on 10/25/2010. There were three surge cords in series under one desk.

2. There was an orange extension cord in use in the south east specialist office as observed at 2:32 p.m. on 10/25/2010.

3. A surge cord passed through a wall between the Pharmacy and the printer closet as observed at 2:55 p.m. on 10/25/2010. The electrical outlet that served this cord had no plate on it.

4. A surge cord was plugged in series in the Patient Account Managers office as observed at 3:20 p.m. on 10/25/2010.

Based on review of the fire plan, the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with NFPA 101 Section 9.7.6.1 (2000) Edition; where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:
An interview with the safety specialist at 10:30 a.m. on 10/26/2010 revealed that the facility did not have a current fire watch policy for the building. The fire watch should include contacting the Department of Public Health & Human Services at 406-444-4170 when a fire watch is instituted.

Based on review of the fire plan, the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with NFPA 101 Section 9.6.1.8 (2000) edition; where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

An interview with the safety specialist at 10:30 a.m. on 10/26/2010 revealed that the facility did not have a current fire watch policy for the building. The fire watch should include contacting the Department of Public Health & Human Services at 406-444-4170 when a fire watch is instituted.

Based on observations made on October 25, 2010, the facility failed to prevent Alcohol Based Hand Rub (ABHR) dispensers from being installed over an ignition source.

The findings include:

In accordance with CMS interpretations (Ref: S&C-05-33) issued on June 9, 2005 Alcohol Based Hand Rub (ABHR) dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. (That is that they be offset by at least one inch from any electrical source).

The "Purell" ABHR dispenser in the south east Specialists office was installed directly above an electrical switch as observed at 2:34 p.m. on 10/25/2010. The dispenser did indeed dispense an alcohol based hand rub solution.