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Based on observations made on June 7, 2011, the facility failed to maintain the fire and smoke resistance rating of wall assemblies.

The findings include:

The "IT" room accessed from the secretary office for the Director of Nursing had a hole for blue colored cable in the wall assembly that had not been sealed as observed at 11:59 a.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to provide for a smoke detector in an open waiting area.

The findings include:

Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 per section 19.3.6.1 of the Life Safety Code (LSC). Exception #2 of 19.3.6.1 of the LSC states that in smoke compartments protected throughout by an approved, supervised automatic sprinkler system waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 square feet.
(b) Each area is protected by an electrically supervised automatic smoke detection system or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.

The waiting area for the Physical Therapy suite in the second floor corridor system was examined at 1:00 p.m. on June 7, 2011. The area was less than 600 square feet in size and was not subject to direct continuous observation. There was no smoke detector in the waiting area to meet exception #2(b) to remain open to the corridor system.

Based on observations made on June 7, 2011, the facility failed to prevent the use of locking devices on exit access doors that do not allow the door to be opened from the egress side by occupants.

The findings include:

Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side per section 19.2.2.2.4 of the Life Safety Code.

1. The exit corridor door to the X-Ray charting room was examined at 10:02 a.m. on June 7, 2011. The door was equipped with a dead bolt style lock that can be locked from the corridor side but the lock cannot be released by the occupant of the room for egress purposes.

2. The exit corridor door to the X-Ray storage room on the second floor level of the building was examined at 10:27 a.m. on June 7, 2011. The door was equipped with a dead bolt style lock that can be locked from the corridor side but the lock cannot be released by the occupant of the room for egress purposes.

3. The CSR is using a bathroom on the second floor (across from the business office) for storage of materials as observed at 11:00 a.m. on June 7, 2011. The corridor door to this bathroom had a hasp and padlock assembly on it that can be locked from the corridor side but the lock cannot be released by the occupant of the room for egress purposes.

Based on observations made on June 7, 2011, the facility failed to prevent the use of roller latches on corridor doors.

The findings include:

The two corridor doors into the Emergency Room were exercised at 12:24 p.m. on June 7, 2011. The latching mechanisms for both doors consisted of a roller latch assembly. There was no positive latching mechanism on these two doors.

Based on observations made on June 7, 2011, the facility failed to assure that all openings onto stairways were protected by at least one-hour rated fire doors with self-closures and positive latching hardware.

The findings include:

The fire rated door to the Nursing Supply storage room (ex-trash room) at the top of the internal stairway from the basement boiler room was exercised at 2:05 p.m. on June 7, 2011. The self-closure device on the door was inhibited from closing and latching the door due to the door binding on the frame.

Based on observations made on June 7, 2011, the facility failed to provide for at least one-hour fire resistive protection for vertical openings.

The finding include:

Any vertical opening shall be enclosed or protected in accordance with 8.2.5. per section 19.3.1.1 of the Life Safety Code (LSC). Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. Openings through floors, such as hoistways for elevators and shaftways used for light, ventilation, or building services shall be enclosed with fire barrier walls per 8.2.5.2 of the LSC. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Self-closing fire rated doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened per section 2-1.4.1 of NFPA 80, 1999 Edition.

1. The elevator shaft was examined on the second floor level at 10:25 a.m. on June 7, 2011. The use of this elevator had been abandoned. Communication wiring was being run through the elevator shaft from the first floor to the second floor. Where the communication wire penetrated the second floor wall of the elevator shaft the opening had not been sealed with a fire rated material to maintain the one-hour fire resistance rating of the shaft.

2. The first floor level of the elevator shaft was examined at 3:35 p.m. on June 7, 2011. The use of this elevator had been abandoned. A one and one-half hour labeled fire door was in place at this level. The door did not have a self-closure device. Furthermore, the latching hardware on the door consisted of a dead bolt lock which was not a positive latching mechanism.

3. The second floor level of the elevator shaft was examined at 3:37 p.m. on June 7, 2011. The use of this elevator had been abandoned. A one and one-half hour labeled fire door was in place at this level. The door did not have a self-closure device. Furthermore, the latching hardware on the door consisted of a dead bolt lock which was not a positive latching mechanism.

Based on observations made on June 7, 2011, the facility failed to maintain the smoke resistive partitions of sprinklered hazardous areas and failed to assure that doors protecting those hazardous areas were supplied with self-closing devices.

The findings include:

1. The medical records room/office had a pipe penetration through the corridor wall that was not sealed to prevent the passage of smoke as observed at 11:42 a.m. on June 7, 2011.

2. The storage room for excess medical records was at least 80 square feet in size and lacked a self-closing device on the corridor door as observed at 11:45 a.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to prevent the use of an exit stairway for storage purposes.

The findings include:

An exit enclosure, including exit stairways and exit passageways, shall not have any open space within the enclosure used for any purpose that has the potential to interfere with egress (an example of a use with the potential to interfere with egress is storage) per sections 7.1.3.2.3 and 7.2.2.5.3 of the Life Safety Code .

A folding table with wheels was being stored in the east exit stairway on the first floor level as observed at 2:49 p.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to provide for separation of an exit stairway from other parts of the building.

The findings include:

Where the Life Safety Code (LSC) requires an exit stairway to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 of the LSC and the separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less per section 7.1.3.2.1 of the LSC. Stairways shall be enclosed with fire barrier walls that shall be continuous from floor to floor and any openings in them shall be protected as appropriate for the fire resistance of the barrier per section 8.2.5.2 of the LSC.

The exit stairway landing at the second floor level adjacent to the Laboratory was open to the corridor system as observed at 10:21 a.m. on June 7, 2011. Note: This deficiency was previously subject to a waiver granted by the Centers for Medicare and Medicaid Services that expired on June 26, 2009.

Based on observations made on June 7, 2011, the facility failed to assure that exits were readily accessible at all times.

The findings include:

The addition to the facility housing the CT Scan unit was examined at 12:10 p.m. on June 7, 2011. The exit door leading to the exterior had boxes of decorations stored directly in front of the door. Note: The boxes were removed after the observation was made to allow access to the exit and confirmed by the surveyor while on-site.

Based on observations made on June 7, 2011, the facility failed to provide for a hard surface path from an exit discharge to the public way.

The findings include:

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 per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The exit stairway adjacent to the Laboratory had an exit discharge that opens onto a lawn area as observed at 10:22 a.m. on June 7, 2011. The most direct path from this exit discharge to the public way was further obstructed by hedges. A hard surface path does not exist from this exit discharge to the public way.

Based on observations and review of records on June 7, 2011, the facility failed to assure that emergency lighting was maintained and operational.

The findings include:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one half 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.

The room housing the CT Scan in the addition to the facility was examined at 12:17 p.m. on June 7, 2011. A battery-powered emergency light fixture was located in the room and tested. The fixture did not illuminate when tested indicating that it may have a dead battery that needs replacement.

Based on review of records on June 7, 2011, the facility failed to assure that emergency lighting was maintained and operational.

The findings include:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half 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.

In reviewing the testing logs for the battery-powered emergency light fixtures the monthly logs were current. There was no documentation available that an annual, one and one-half hour test had been conducted on the battery-powered fixtures. This deficiency pertains to both building 01 and 02.

Based on observations made on June 7, 2011, the facility failed to properly mark the electrical breaker supplying power to the Fire Alarm Control Panel. Further, the facility failed to provide for a smoke detector, or in certain cases a heat detector, in the room housing the Fire Alarm Control Panel (FACP).

The findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s) per section 1-5.2.5.2 of NFPA 72, 1999 Edition. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering.

1. The FACP located in the boiler room had the location of the circuit disconnecting means permanently identified as breaker #40 in panel board D as observed at 2:17 p.m. on June 7, 2011. However, the breaker itself located in panel board D did not have a red marking identifying itself as the breaker controlling the FACP.

In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each FACP to provide notification of fire at that location with the exception that where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted per section 1-5.6 of NFPA 72, 1999 Edition.

2. The boiler room, which is not continuously occupied, located on the first floor of the building houses the Fire Alarm Control Panel. No smoke detector, or heat detector dependent upon the conditions in the room, was observed to be above the Fire Alarm Control Panel when examined at 3:31 p.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to provide for complete sprinkler protection of the building.

The findings include:

The construction type of this building is Type III (211) which requires it be fully sprinklered and not over two stories in height.

The vertical shaft that previously housed the fresh air intake ductwork serving as the combustion air source for the previous generator on the first floor of the building was examined at 11:48 a.m. on June 7, 2011. Both the generator and the duct work had been removed and storage of combustible items at the bottom of the shaft was evident. With the removal of the duct work, it was determined that there was no sprinkler protection at the top of the shaft to provide coverage for use areas under that shaft.

Based on observations and review of records or logs available on June 7, 2011, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semi-annual basis.

The findings include:

The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction at frequent intervals, at least semiannually, prior to surfaces becoming heavily contaminated with grease or oily sludge per section 8-3.1 of NFPA 96, 1998 Edition. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction per section 8-3.1.1 of NFPA 96. When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company per 8-3.1.2 of NFPA 96.

The kitchen hood exhaust system was examined at 1:55 p.m. on June 7, 2011. No documentation was available that the exhaust hood had been inspected and/or cleaned on a semiannual basis.

Based on observations made on June 7, 2011, the facility failed to prevent the use of a portable heater in a patient treatment area of the building.

The findings include:

A "Lakewood" brand portable heater was observed to be located in the X-Ray room at 10:00 a.m. on June 7, 2011. Although not plugged into a receptacle, the heater was available for use in a resident treatment area where portable heaters are prohibited.

Based on observations made on June 7, 2011, the facility failed to provide documentation that numerous window curtains and valances were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

1. The previous Nursing Home side of the facility was toured between 12:00 p.m. and 3:45 p.m. on June 7, 2011. During the course of the tour of this building, it was noted that valances of the same design were in the majority of resident/patient rooms on both levels. There was no documentation that these valances met the flame resistant properties required by NFPA 701.

2. Both the open and enclosed waiting areas for the Emergency Room were examined at 12:27 p.m. on June 7, 2011. Open white lace style curtains were in use in both areas. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

3. The window curtains in the room adjacent to the main bathing room on the second floor level were examined at 1:39 p.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

Based on observations made on June 7, 2011, the facility failed to provide documentation that numerous window curtains and valances were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

1. The window curtains in room 202 were examined at 10:19 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

2. The window curtains in the bathroom off of the X-Ray storage room on the second floor were examined at 10:47 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

3. The window curtains and the cubicle curtain in the "Dexa" scan room were examined at 11:02 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

4. The window curtains in the activity office (room 206) were examined at 11:11 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

5. The window curtains in room 207 were examined at 11:12 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

6. The window curtains in room 208 were examined at 11:13 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

7. The hanging drapes in the Laundry office were examined at 11:22 a.m. on June 7, 2011. There was no documentation that these drapes met the flame resistant properties required by NFPA 701.

8. The window valances in the Administrator's Office were examined at 12:06 p.m. on June 7, 2011. There was no documentation that these valances met the flame resistant properties required by NFPA 701.

Based on observations made on June 7, 2011, the facility failed to prevent oxygen cylinders from being subject to falling or being knocked down.

The findings include:

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 per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

Two small oxygen cylinders were observed to be freestanding in the corridor outside of room 220 at 1:32 p.m. on June 7, 2011 and not properly secured against falling or being knocked over.

Based on observations made on June 7, 2011, the facility failed to provide for a chemical spill kit located within the work area of the Laboratory.

The findings include:

The Laboratory of the facility was toured between 10:05 and 10:10 a.m. on June 7, 2011. During the tour it was determined that there was no spill kit available in the Laboratory for use in case of a chemical spill.

Based on observations made on June 7, 2011, the facility failed to provide for an emergency shower located within the work area of the Laboratory.

The findings include:

The Laboratory of the facility was toured between 10:05 and 10:10 a.m. on June 7, 2011. During the tour, it was determined that there was no emergency shower available for quick drenching or flushing of the eyes and body for immediate use in the Laboratory.

Based on observations made on June 7, 2011, the facility failed to provide for one-hour separation, including fire doors, of a room where transferring of liquid oxygen takes place and failed to have available a sign to indicate that such transfer was occurring.

The findings include:

The oxygen storage room used for the transfer of liquid oxygen was located on the second floor of the building. The room did have mechanical ventilation and concrete floors as observed at 10:37 a.m. on June 7, 2011. The walls and ceiling assembly of the room meet a one-hour fire resistive rating and a no smoking sign was posted at the entry door. The door to this room was not labeled as at least a 3/4 hour fire door and lacked a self-closure device. Furthermore, there was no sign available to be attached to the outside of the door to signify that oxygen transfer was taking place whenever filling procedures were in operation.

Based on review of the test logs for the two emergency generators on June 7, 2011, the facility failed to assure that load tests were conducted each month.

The findings include:

The testing logs for the two emergency generators were reviewed at the facility on June 7, 2011. No documentation was available to verify that the generators were tested under load conditions during the month of August 2010. This deficiency pertains to both building 01 and 02.

Based on observations made on June 7, 2011, the facility failed to properly identify the automatic transfer switches serving the emergency system (life safety and critical branches) and the equipment system of the Essential Electrical System (EES).

The findings include:

The facility had automatic transfer switches for the EES located outside in the enclosure for the two generators and inside the building in the combination central storage/electrical panel room as observed during the tour of the building on June 7, 2011. None of the automatic transfer switches had any identification as to the branches of the EES that they served. Note: A waiver from CMS was granted for this deficiency on August 1, 2007 and expired on June 26, 2009 as the facility was in the process of replacement of the original generator with two new generators. The EES was to be divided into the three branches upon completion of the replacement. This deficiency pertains to both buildings 01 and 02.

Based on observations made on June 7, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

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 per Article 370.28(c) of NFPA 70.

1. An open electrical junction box above the computer in the Laboratory was missing its cover plate as observed at 10:11 a.m. on June 7, 2011.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

2. Electrical panel board P3 located in the central supply/electrical room was examined at 10:52 a.m. on June 7, 2011. The Ground Fault Circuit Interrupter breakers numbered 5, 7 and 9 had no listing as to what service they provided or if they were spares. They were observed to be in the "on" position for service.

3. The electrical panel board located in the old boiler room was examined at 11:29 a.m. on June 7, 2011. Due to the past heat and humidity in this room, the placard listing the service for each breaker had deteriorated to the point where many of the listings were unreadable.

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 (CMS), 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.

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 the power strip.

4. A multiple adaptor without built-in circuit breaker protection was in use in the second floor break room as observed at 11:10 a.m. on June 7, 2011. Furthermore, a microwave was plugged into this multiple adaptor instead of directly into a receptacle.

5. A microwave and a refrigerator both were plugged into the same power strip in the housekeeping office as observed at 11:47 a.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition.

The findings include:

Flexible cords shall not be run through doorways, windows or similar openings per Article 400-8 of NFPA 70.

1. An oxygen concentrator was in use in room 220 as observed at 1:32 p.m. on June 7, 2011. The cord for the concentrator was run through the bathroom doorway of this room.

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 per Article 370.28(c) of NFPA 70.

2. An electrical junction box for light fixtures located in the ceiling of the maintenance/repair shop was missing its cover plate as observed at 2:15 p.m. on June 7, 2011.

Based on review of the fire policies and procedures of the facility on June 7, 2011, the facility failed to implement requirements for fire watches or evacuation whenever the fire sprinkler system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on June 7, 2011. The policies or procedures did not include safety measures to be taken when the fire sprinkler system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.7.6.1 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building. This deficiency pertains to both building 01 and 02.

Based on review of the fire policies and procedures of the facility on June 7, 2011, the facility failed to implement requirements for fire watches or evacuation whenever the fire alarm system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on June 7, 2011. The policies or procedures did not include safety measures to be taken when the fire alarm system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.6.1.8 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building. This deficiency pertains to both building 01 and 02.

Based on observations made on June 7, 2011, the facility failed to maintain the fire and smoke resistance rating of wall assemblies.

The findings include:

The "IT" room accessed from the secretary office for the Director of Nursing had a hole for blue colored cable in the wall assembly that had not been sealed as observed at 11:59 a.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to provide for a smoke detector in an open waiting area.

The findings include:

Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 per section 19.3.6.1 of the Life Safety Code (LSC). Exception #2 of 19.3.6.1 of the LSC states that in smoke compartments protected throughout by an approved, supervised automatic sprinkler system waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(a) The aggregate waiting area in each smoke compartment does not exceed 600 square feet.
(b) Each area is protected by an electrically supervised automatic smoke detection system or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.
(c) The area does not obstruct access to required exits.

The waiting area for the Physical Therapy suite in the second floor corridor system was examined at 1:00 p.m. on June 7, 2011. The area was less than 600 square feet in size and was not subject to direct continuous observation. There was no smoke detector in the waiting area to meet exception #2(b) to remain open to the corridor system.

Based on observations made on June 7, 2011, the facility failed to prevent the use of locking devices on exit access doors that do not allow the door to be opened from the egress side by occupants.

The findings include:

Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side per section 19.2.2.2.4 of the Life Safety Code.

1. The exit corridor door to the X-Ray charting room was examined at 10:02 a.m. on June 7, 2011. The door was equipped with a dead bolt style lock that can be locked from the corridor side but the lock cannot be released by the occupant of the room for egress purposes.

2. The exit corridor door to the X-Ray storage room on the second floor level of the building was examined at 10:27 a.m. on June 7, 2011. The door was equipped with a dead bolt style lock that can be locked from the corridor side but the lock cannot be released by the occupant of the room for egress purposes.

3. The CSR is using a bathroom on the second floor (across from the business office) for storage of materials as observed at 11:00 a.m. on June 7, 2011. The corridor door to this bathroom had a hasp and padlock assembly on it that can be locked from the corridor side but the lock cannot be released by the occupant of the room for egress purposes.

Based on observations made on June 7, 2011, the facility failed to prevent the use of roller latches on corridor doors.

The findings include:

The two corridor doors into the Emergency Room were exercised at 12:24 p.m. on June 7, 2011. The latching mechanisms for both doors consisted of a roller latch assembly. There was no positive latching mechanism on these two doors.

Based on observations made on June 7, 2011, the facility failed to assure that all openings onto stairways were protected by at least one-hour rated fire doors with self-closures and positive latching hardware.

The findings include:

The fire rated door to the Nursing Supply storage room (ex-trash room) at the top of the internal stairway from the basement boiler room was exercised at 2:05 p.m. on June 7, 2011. The self-closure device on the door was inhibited from closing and latching the door due to the door binding on the frame.

Based on observations made on June 7, 2011, the facility failed to provide for at least one-hour fire resistive protection for vertical openings.

The finding include:

Any vertical opening shall be enclosed or protected in accordance with 8.2.5. per section 19.3.1.1 of the Life Safety Code (LSC). Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. Openings through floors, such as hoistways for elevators and shaftways used for light, ventilation, or building services shall be enclosed with fire barrier walls per 8.2.5.2 of the LSC. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Self-closing fire rated doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened per section 2-1.4.1 of NFPA 80, 1999 Edition.

1. The elevator shaft was examined on the second floor level at 10:25 a.m. on June 7, 2011. The use of this elevator had been abandoned. Communication wiring was being run through the elevator shaft from the first floor to the second floor. Where the communication wire penetrated the second floor wall of the elevator shaft the opening had not been sealed with a fire rated material to maintain the one-hour fire resistance rating of the shaft.

2. The first floor level of the elevator shaft was examined at 3:35 p.m. on June 7, 2011. The use of this elevator had been abandoned. A one and one-half hour labeled fire door was in place at this level. The door did not have a self-closure device. Furthermore, the latching hardware on the door consisted of a dead bolt lock which was not a positive latching mechanism.

3. The second floor level of the elevator shaft was examined at 3:37 p.m. on June 7, 2011. The use of this elevator had been abandoned. A one and one-half hour labeled fire door was in place at this level. The door did not have a self-closure device. Furthermore, the latching hardware on the door consisted of a dead bolt lock which was not a positive latching mechanism.

Based on observations made on June 7, 2011, the facility failed to maintain the smoke resistive partitions of sprinklered hazardous areas and failed to assure that doors protecting those hazardous areas were supplied with self-closing devices.

The findings include:

1. The medical records room/office had a pipe penetration through the corridor wall that was not sealed to prevent the passage of smoke as observed at 11:42 a.m. on June 7, 2011.

2. The storage room for excess medical records was at least 80 square feet in size and lacked a self-closing device on the corridor door as observed at 11:45 a.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to prevent the use of an exit stairway for storage purposes.

The findings include:

An exit enclosure, including exit stairways and exit passageways, shall not have any open space within the enclosure used for any purpose that has the potential to interfere with egress (an example of a use with the potential to interfere with egress is storage) per sections 7.1.3.2.3 and 7.2.2.5.3 of the Life Safety Code .

A folding table with wheels was being stored in the east exit stairway on the first floor level as observed at 2:49 p.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to provide for separation of an exit stairway from other parts of the building.

The findings include:

Where the Life Safety Code (LSC) requires an exit stairway to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 of the LSC and the separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less per section 7.1.3.2.1 of the LSC. Stairways shall be enclosed with fire barrier walls that shall be continuous from floor to floor and any openings in them shall be protected as appropriate for the fire resistance of the barrier per section 8.2.5.2 of the LSC.

The exit stairway landing at the second floor level adjacent to the Laboratory was open to the corridor system as observed at 10:21 a.m. on June 7, 2011. Note: This deficiency was previously subject to a waiver granted by the Centers for Medicare and Medicaid Services that expired on June 26, 2009.

Based on observations made on June 7, 2011, the facility failed to assure that exits were readily accessible at all times.

The findings include:

The addition to the facility housing the CT Scan unit was examined at 12:10 p.m. on June 7, 2011. The exit door leading to the exterior had boxes of decorations stored directly in front of the door. Note: The boxes were removed after the observation was made to allow access to the exit and confirmed by the surveyor while on-site.

Based on observations made on June 7, 2011, the facility failed to provide for a hard surface path from an exit discharge to the public way.

The findings include:

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 per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The exit stairway adjacent to the Laboratory had an exit discharge that opens onto a lawn area as observed at 10:22 a.m. on June 7, 2011. The most direct path from this exit discharge to the public way was further obstructed by hedges. A hard surface path does not exist from this exit discharge to the public way.

Based on observations and review of records on June 7, 2011, the facility failed to assure that emergency lighting was maintained and operational.

The findings include:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one half 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.

The room housing the CT Scan in the addition to the facility was examined at 12:17 p.m. on June 7, 2011. A battery-powered emergency light fixture was located in the room and tested. The fixture did not illuminate when tested indicating that it may have a dead battery that needs replacement.

Based on review of records on June 7, 2011, the facility failed to assure that emergency lighting was maintained and operational.

The findings include:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half 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.

In reviewing the testing logs for the battery-powered emergency light fixtures the monthly logs were current. There was no documentation available that an annual, one and one-half hour test had been conducted on the battery-powered fixtures. This deficiency pertains to both building 01 and 02.

Based on observations made on June 7, 2011, the facility failed to properly mark the electrical breaker supplying power to the Fire Alarm Control Panel. Further, the facility failed to provide for a smoke detector, or in certain cases a heat detector, in the room housing the Fire Alarm Control Panel (FACP).

The findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s) per section 1-5.2.5.2 of NFPA 72, 1999 Edition. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering.

1. The FACP located in the boiler room had the location of the circuit disconnecting means permanently identified as breaker #40 in panel board D as observed at 2:17 p.m. on June 7, 2011. However, the breaker itself located in panel board D did not have a red marking identifying itself as the breaker controlling the FACP.

In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each FACP to provide notification of fire at that location with the exception that where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted per section 1-5.6 of NFPA 72, 1999 Edition.

2. The boiler room, which is not continuously occupied, located on the first floor of the building houses the Fire Alarm Control Panel. No smoke detector, or heat detector dependent upon the conditions in the room, was observed to be above the Fire Alarm Control Panel when examined at 3:31 p.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to provide for complete sprinkler protection of the building.

The findings include:

The construction type of this building is Type III (211) which requires it be fully sprinklered and not over two stories in height.

The vertical shaft that previously housed the fresh air intake ductwork serving as the combustion air source for the previous generator on the first floor of the building was examined at 11:48 a.m. on June 7, 2011. Both the generator and the duct work had been removed and storage of combustible items at the bottom of the shaft was evident. With the removal of the duct work, it was determined that there was no sprinkler protection at the top of the shaft to provide coverage for use areas under that shaft.

Based on observations and review of records or logs available on June 7, 2011, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semi-annual basis.

The findings include:

The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction at frequent intervals, at least semiannually, prior to surfaces becoming heavily contaminated with grease or oily sludge per section 8-3.1 of NFPA 96, 1998 Edition. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction per section 8-3.1.1 of NFPA 96. When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company per 8-3.1.2 of NFPA 96.

The kitchen hood exhaust system was examined at 1:55 p.m. on June 7, 2011. No documentation was available that the exhaust hood had been inspected and/or cleaned on a semiannual basis.

Based on observations made on June 7, 2011, the facility failed to prevent the use of a portable heater in a patient treatment area of the building.

The findings include:

A "Lakewood" brand portable heater was observed to be located in the X-Ray room at 10:00 a.m. on June 7, 2011. Although not plugged into a receptacle, the heater was available for use in a resident treatment area where portable heaters are prohibited.

Based on observations made on June 7, 2011, the facility failed to provide documentation that numerous window curtains and valances were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

1. The previous Nursing Home side of the facility was toured between 12:00 p.m. and 3:45 p.m. on June 7, 2011. During the course of the tour of this building, it was noted that valances of the same design were in the majority of resident/patient rooms on both levels. There was no documentation that these valances met the flame resistant properties required by NFPA 701.

2. Both the open and enclosed waiting areas for the Emergency Room were examined at 12:27 p.m. on June 7, 2011. Open white lace style curtains were in use in both areas. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

3. The window curtains in the room adjacent to the main bathing room on the second floor level were examined at 1:39 p.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

Based on observations made on June 7, 2011, the facility failed to provide documentation that numerous window curtains and valances were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

1. The window curtains in room 202 were examined at 10:19 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

2. The window curtains in the bathroom off of the X-Ray storage room on the second floor were examined at 10:47 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

3. The window curtains and the cubicle curtain in the "Dexa" scan room were examined at 11:02 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

4. The window curtains in the activity office (room 206) were examined at 11:11 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

5. The window curtains in room 207 were examined at 11:12 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

6. The window curtains in room 208 were examined at 11:13 a.m. on June 7, 2011. There was no documentation that these curtains met the flame resistant properties required by NFPA 701.

7. The hanging drapes in the Laundry office were examined at 11:22 a.m. on June 7, 2011. There was no documentation that these drapes met the flame resistant properties required by NFPA 701.

8. The window valances in the Administrator's Office were examined at 12:06 p.m. on June 7, 2011. There was no documentation that these valances met the flame resistant properties required by NFPA 701.

Based on observations made on June 7, 2011, the facility failed to prevent oxygen cylinders from being subject to falling or being knocked down.

The findings include:

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 per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

Two small oxygen cylinders were observed to be freestanding in the corridor outside of room 220 at 1:32 p.m. on June 7, 2011 and not properly secured against falling or being knocked over.

Based on observations made on June 7, 2011, the facility failed to provide for an emergency shower located within the work area of the Laboratory.

The findings include:

The Laboratory of the facility was toured between 10:05 and 10:10 a.m. on June 7, 2011. During the tour, it was determined that there was no emergency shower available for quick drenching or flushing of the eyes and body for immediate use in the Laboratory.

Based on observations made on June 7, 2011, the facility failed to provide for one-hour separation, including fire doors, of a room where transferring of liquid oxygen takes place and failed to have available a sign to indicate that such transfer was occurring.

The findings include:

The oxygen storage room used for the transfer of liquid oxygen was located on the second floor of the building. The room did have mechanical ventilation and concrete floors as observed at 10:37 a.m. on June 7, 2011. The walls and ceiling assembly of the room meet a one-hour fire resistive rating and a no smoking sign was posted at the entry door. The door to this room was not labeled as at least a 3/4 hour fire door and lacked a self-closure device. Furthermore, there was no sign available to be attached to the outside of the door to signify that oxygen transfer was taking place whenever filling procedures were in operation.

Based on review of the test logs for the two emergency generators on June 7, 2011, the facility failed to assure that load tests were conducted each month.

The findings include:

The testing logs for the two emergency generators were reviewed at the facility on June 7, 2011. No documentation was available to verify that the generators were tested under load conditions during the month of August 2010. This deficiency pertains to both building 01 and 02.

Based on observations made on June 7, 2011, the facility failed to properly identify the automatic transfer switches serving the emergency system (life safety and critical branches) and the equipment system of the Essential Electrical System (EES).

The findings include:

The facility had automatic transfer switches for the EES located outside in the enclosure for the two generators and inside the building in the combination central storage/electrical panel room as observed during the tour of the building on June 7, 2011. None of the automatic transfer switches had any identification as to the branches of the EES that they served. Note: A waiver from CMS was granted for this deficiency on August 1, 2007 and expired on June 26, 2009 as the facility was in the process of replacement of the original generator with two new generators. The EES was to be divided into the three branches upon completion of the replacement. This deficiency pertains to both buildings 01 and 02.

Based on observations made on June 7, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

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 per Article 370.28(c) of NFPA 70.

1. An open electrical junction box above the computer in the Laboratory was missing its cover plate as observed at 10:11 a.m. on June 7, 2011.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

2. Electrical panel board P3 located in the central supply/electrical room was examined at 10:52 a.m. on June 7, 2011. The Ground Fault Circuit Interrupter breakers numbered 5, 7 and 9 had no listing as to what service they provided or if they were spares. They were observed to be in the "on" position for service.

3. The electrical panel board located in the old boiler room was examined at 11:29 a.m. on June 7, 2011. Due to the past heat and humidity in this room, the placard listing the service for each breaker had deteriorated to the point where many of the listings were unreadable.

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 (CMS), 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.

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 the power strip.

4. A multiple adaptor without built-in circuit breaker protection was in use in the second floor break room as observed at 11:10 a.m. on June 7, 2011. Furthermore, a microwave was plugged into this multiple adaptor instead of directly into a receptacle.

5. A microwave and a refrigerator both were plugged into the same power strip in the housekeeping office as observed at 11:47 a.m. on June 7, 2011.

Based on observations made on June 7, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition.

The findings include:

Flexible cords shall not be run through doorways, windows or similar openings per Article 400-8 of NFPA 70.

1. An oxygen concentrator was in use in room 220 as observed at 1:32 p.m. on June 7, 2011. The cord for the concentrator was run through the bathroom doorway of this room.

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 per Article 370.28(c) of NFPA 70.

2. An electrical junction box for light fixtures located in the ceiling of the maintenance/repair shop was missing its cover plate as observed at 2:15 p.m. on June 7, 2011.

Based on review of the fire policies and procedures of the facility on June 7, 2011, the facility failed to implement requirements for fire watches or evacuation whenever the fire sprinkler system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on June 7, 2011. The policies or procedures did not include safety measures to be taken when the fire sprinkler system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.7.6.1 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building. This deficiency pertains to both building 01 and 02.

Based on review of the fire policies and procedures of the facility on June 7, 2011, the facility failed to implement requirements for fire watches or evacuation whenever the fire alarm system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on June 7, 2011. The policies or procedures did not include safety measures to be taken when the fire alarm system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.6.1.8 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building. This deficiency pertains to both building 01 and 02.