HospitalInspections.org

Based on observations made on July 18 and 19, 2011, 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, Life Safety Code (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 set of fire doors between PAC-U and the reception waiting area of the ground floor of the Surgery Center were exercised at 7:55 a.m. on July 19, 2011. The set of fire doors failed to latch when exercised on three tries.

2. The sprinkler riser room, which borders the fire wall between PAC-U and the waiting area of the ground floor, was observed at 8:14 a.m. on July 19, 2011. The corridor wall had a one-half inch conduit which was not sealed.

3. The 1-hour rated set of fire doors between the corridor and the elevator on second floor of the hospital were exercised at 9:07 a.m. on July 19, 2011. The doors failed to latch when exercised on three different tries.

4. The short hall leading to Central Montana Medical Office Building (MOB), near the main entrance and along the west side of the building, was observed at 10:05 a.m. on July 19, 2011. The following unsealed penetrations were found:

a) One four inch penetration was found in the west fire wall above the ceiling tile, and

b) One penetration was found in the south wall above the door leading into MOB for a cable.

5. The fire wall between PAC-U and the waiting area was observed at 10:12 a.m. on July 19, 2011. The fire wall above the set of doors leading into PAC-U had some of the fire tape peeling off, as there was no joint compound applied over the tape.

Based on observations made during a survey of July 18 and 19, 2011, it has been determined that the facility did not maintain the fire resistive rating of wall and ceiling assemblies.

Findings include:

1. The air-handling room in the south west corner of the basement of the Surgical Center was observed at 11:15 a.m. on July 18, 2011. Two ceiling tiles were out of place in this room.

2. The Data room and the Conference room, in the basement of the Surgical Center, were observed at 1:00 p.m. on July 18, 2011.

a) There was five penetrations in the wall which separates the Data room from the Conference room, for communication cable.

b) There were three penetrations in the south wall of the Data room for communication wiring at conduits.

3. The MRI Data room located in the basement of the Surgical Center was observed at 1:18 p.m. on July 18, 2011. Six ceiling tiles were out of place in this room.

4. The Break room in the basement of the Surgical Center was observed at 1:57 p.m. on July 18, 2011. There were two Internet cords through the ceiling tile preventing the tiles from laying flat in the suspended grid.

5. The Accounting office off of the Break room in the basement of the Surgical Center was observed at 2:00 p.m. on July 18, 2011. There was one Internet cord through the ceiling tile preventing the tiles from laying flat in the suspended grid.

6. The Insurance Follow-up office off of the Break room in the basement of the Surgical Center was observed at 2:01 p.m. on July 18, 2011. There was one Internet cord through the ceiling tile preventing the tiles from laying flat in the suspended grid.

7. The Soiled Utility room on the second floor of the Hospital was observed at 9:20 a.m. on July 19, 2011. There was a ceiling tile missing in this room.

8. The short hall leading to MOB, on the west side main entrance to the Hospital was observed at 10:10 a.m. on July 19, 2011. There was one penetration in the north wall above the ceiling tile near the two steps leading to the Data Room for MOB.

9. The Sterile store room in the basement of the Surgical Center was observed at 2:00 p.m. on July 18, 2011. A speaker had been installed above the ceiling tile, and a two inch round hole had been cut in the tile and was not sealed.

Based on observations which were made on July 18 and 19, 2011, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

1. The Ball room in the lower level of the Surgical Hospital was observed at 2:31 p.m. on July 18, 2011. There was a penetration of the east corridor wall at the midpoint area where a one-half inch conduit was not properly sealed.

2. The ground floor Electrical room of the Hospital was observed at 8:20 a.m. on July 19, 2011. There was a three-quarter inch conduit through the north wall of the Electrical room which was not sealed.

Based on observation on July 18 & 19, 2011, the facility did not ensure all exit corridor doors were free from impediments that prevent them being held open by means not acceptable to the Life Safety Code.

Findings included:

In accordance with 19.3.6.3.3 of the Life Safety Code hold-open devices that release when the door is pushed or pulled shall be permitted (this does not apply to hazardous area protection). Doors can not be blocked open by furniture, door stops, chocks or devices that necessitate manual releasing action to close the door. Further guidance from Annex A and specifically section A.19.3.6.3.3 states that 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. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

1. The Internet Technology (IT) office corridor door was blocked open with a wedge as observed at 2:49 p.m. on July 18, 2011.

2. The corridor door to the Staff Supply storeroom on the second level of the Hospital was blocked open with a wedge as observed at 9:22 a.m. on July 19, 2011.

Based on observations made on July 18 and 19, 2011, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

The findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The north side storeroom in the basement of the Surgery Center was observed at 12:50 p.m. on July 18, 2011. One vent tube through the ceiling to the level above was not properly sealed with a material rated for fire resistive construction.

2. The Tool Crib (elevator shaft) in the lower level of the Surgery Center was observed at 2:08 p.m. on July 18, 2011. The door to the shaft was blocked open with a wedge.

3. The Ball room in the basement of the Hospital was observed at 2:30 p.m. on July 18, 2011. The four foot by five foot shaft leading to the level above which is located directly above the entrance door to the room was not fire taped.

4. The Sump room in the basement of the Hospital was observed at 2:40 p.m. on July 18, 2011. The ceiling along the west wall had three penetrations through to the deck above. All were conduits which were not properly sealed with a material capable of maintaining the fire resistance of the barrier.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The Sump room in the basement of the Hospital was observed at 2:38 p.m. on July 18, 2011.

a) There were two penetration through the southeast corner of the west wall near the ceiling which were not sealed.

b) There were two penetrations in the north wall for conduit which contained communication cable which were not sealed.

2. The set of smoke barrier doors between rooms 105 and 106 of the Hospital were exercised at 8:30 a.m. on July 19, 2011. The doors failed to latch when exercised on three different tries.

3. The set of smoke barrier doors between the Nursing Supervisors office and the exit corridor were exercised at 8:40 a.m. on July 19, 2011. The doors failed to latch when exercised on three different tries.

4. The smoke wall above the smoke barrier doors next to MRI on first floor of the Surgical Center was observed at 10:15 a.m. on July 19, 2011.

a) Two 3/4 inch water pipes were not sealed above the smoke barrier doors

b) There was also a one inch penetration in the wall which was not sealed.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain the fire rated assemblies protecting smoke compartments, and assure that smoke barrier doors closed flush with each other at the meeting edges to prevent the passage of smoke.

The findings include:

1. Smoke barrier doors protecting smoke compartments were checked to see if the assemblies prevented the passage of smoke between compartments. The 1 hour rated smoke barrier door between the south Nursing Station and Medication Room on the main level of the Hospital was exercised at 8:42 a.m. on July 19, 2011. The smoke barrier door failed to latch properly when exercised on three different tries.

2. The set of 1-hour rated smoke barrier doors between the Medical Office Building (MOB) and the ground floor women's restroom was exercised at 9:10 a.m. on July 19, 2011. The set of smoke barrier doors failed to latch when exercised during three different tries.

3. The smoke barrier wall which separates the MRI area in the basement of the Hospital was observed at 1:50 p.m. on July 19, 2011. The large lead door in the smoke barrier wall of MRI was not self-closing.

Based on observation, the facility failed to provide self-closing doors on all hazardous areas and to keep all hazardous areas properly protected.

Findings include:

In accordance with NFPA 101 and section 19.3.2.1 Hazardous Areas, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Section 8.4.1.3 of NFPA 101, Life Safety Code states: Doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

1. The soiled laundry room in the basement of the Surgical Center was observed at 12:45 p.m. on July 18, 2011. The corridor door to this room failed to latch when exercised on three different tries.

2. The storage room along the north side of the basement of the Surgical Center was observed at 12:55 p.m. on July 18, 2011. A vent tube through the wall was not sealed in this room.

3. The MRI Data room in the lower level of the Surgical Center was observed at 1:15 p.m. on July 18, 2011. The corridor door to this store room was blocked open with a dust pan.

4. The boiler room in the lower level of the Surgical Center was observed at 1:20 p.m. on July 18, 2011.

a) The north wall had a penetration of a one-half inch conduit for electrical wiring which was not sealed.

b) The west wall had two penetrations which were not sealed, one was a hot water line in the north west corner and the remaining was a one-half inch conduit for electrical wiring above the electrical cabinet labeled Air Handling Unit (AHU) #1.

5. The door to the soiled utility room in the rear of PAC-U was not self-closing as observed at 7:55 a.m. on July 19, 2011.

6. The boiler room on the second floor of the Hospital was observed at 9:32 a.m. on July 19, 2011. The ceiling of this room is not covered with joint compound over all screws and sheet rock seams to complete the fire resistance of the ceiling.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain exit stair gates to prevent patients, staff, and members of the public from going to the lower level in an exit stairway.

According to Section 7.7.3 of NFPA 101, stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Findings include:

1. The southwest stairway of the Hospital building was reviewed at 8:17 a.m. on July 19, 2011. There was no gate in the stairway preventing patients, staff, and members of the public from going to the lower level during emergency evacuation.

2. The northeast stairway of the Hospital building was reviewed at 10:30 a.m. on July 19, 2011. There was no gate in the stairway preventing patients, staff, and members of the public from going to the lower level during emergency evacuation.

Based on review of battery powered emergency light fixture testing logs and interview with maintenance staff on July 18, 2011, the facility did not ensure that the required 30 second monthly and 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 surveyor asked to review the logs/records for the battery powered emergency light fixtures at 11:05 a.m. on July 18, 2011.

An interview with staff member A at this same time revealed that testing of the battery pack emergency lighting for 2010 -2011 was not done. When questioned about the monthly and annual testing, staff member A indicated the facility did not know about the requirement for 30 second monthly and 90 minute annual testing of emergency battery pack lighting fixtures. Hence, there was no record. He also stated that the only fixtures he was testing were located in the operating rooms and recovery rooms, and that he was performing about a 15 second monthly test of the fixtures. He also stated that several batteries had to be replaced as they would no longer retain a charge.

Twenty six light fixtures were tested during the survey process, we may have missed one or two along the way, as they did not know how many units were installed in the two buildings.

2. The battery powered emergency light fixture located in the elevator mechanical room in the basement of the Surgery Center was checked at 2:05 p.m. on July 18, 2011. The fixture failed to illuminate when tested.

Based on staff interview and review of the fire drill reports made on July 18, 2011, the facility failed to assure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift.

The findings include:

In accordance with Section 19.7.1.2 of NFPA 101, Life Safety Code; which states: fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms.

The fire drill reports were reviewed at 11:00 a.m. on July 18, 2011. No written documentation was found that a fire drills had been conducted on the following:

a.) night shift (7:00 p.m. to 7:00 a.m.) during the third quarter (July, August, September) of 2010,
b.) day shift (7:00 a.m. to 7:00 p.m.) during the fourth quarter (October, November, December) of 2010,
c.) night shift (7:00 p.m. to 7:00 a.m.) during the fourth quarter (October, November, December) of 2010, and
d.) night shift (7:00 p.m. to 7:00 a.m.) during the first quarter (January, February, March) of 2011.

Interview with facility staff at the time of the exit revealed that staff thought that they could perform drills at the shift change and catch both shifts. Three out of the four drills which were completed in the past year were completed at the shift change (0700 to 0730).

Based on review of the fire alarm service reports on July 18, 2011, the facility did not ensure that sensitivity testing results were available for the years 2008 through 2011.

Findings included:

Smoke detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per 7-3.2.1 of NFPA 72, 1999 Edition. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range or 4 percent obscuration light gray smoke, if not marked, the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. It is being required by the Centers for Medicare and Medicaid Services (CMS), as the authority having jurisdiction, that those systems that automatically monitor sensitivity shall have a paper printout available verifying the calibration of each detector.

The fire alarm service reports were reviewed at the facility on July 18, 2011. There was no written documentation or report that indicated the contractor had printed the sensitivity testing results in 2011 or previously. Hard copy documentation of smoke alarm sensitivities must be available in the facility when requested.

Based on observation on July 18 & 19, 2011, the facility failed to keep the proper number of spare heads in the spare head cabinets in the Hospital and Surgical Center sprinkler riser rooms, monitor fire suppression systems, and maintain sprinkler system components.

Findings include:

In accordance with Section 2-2.1.3 of NFPA 25, 1998 edition, the supply of spare sprinklers shall be inspected annually for the following: (a) The proper number and type of sprinklers (b) A sprinkler wrench for each type of sprinkler.

In accordance with Section 2-4.1.4 of NFPA 25, 1998 Edition, a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

1. The spare head cabinet sprinkler riser room of the Hospital was observed at 9:52 a.m. on July 18, 2011. The cabinet lacked a minimum of six heads for each type of sprinkler head that the facility may have. The Code requires the facility to have at least six spare heads of each type sprinkler which the facility may have.

2. The spare head cabinet in the sprinkler riser room of the Surgical Center was observed at 9:04 a.m. on July 19, 2011. The cabinet lacked a minimum of six heads for each type of sprinkler head that the facility may have. The Code requires the facility to have at least six spare heads of each type sprinkler which the facility may have.

3. The Bulk storeroom in the basement of the Surgical Center was observed at 12:57 p.m. on July 18, 2011. There were two sprinkler heads missing escutcheon rings.

4. The MRI Data room was observed at 1:15 p.m. on July 18, 2011. The (Reliable Model H Prepak) fire suppression system which serves this room was in alarm mode, indicating that there was low air pressure in zone four of the system. An audible and visible alarm was being indicated on the digital readout board, but no one that the surveyor spoke to was aware of the alarm. The corridor door to this room was blocked open, ceiling tiles had been taken out but no one was working on the system. This surveyor checked the room on three different occasions that same afternoon. The system was in alarm mode, all afternoon, with the corridor door being blocked open and ceiling tiles taken out. At 4:15 p.m. the surveyor reported the findings to personnel in MRI and they said that they would contact the contracted authority for the system.

5. The closet in the Case Management office on the main level of the Surgical Center was observed at 9:02 a.m. on July 19, 2011. An escutcheon ring was down from the ceiling tile approximately one half inch, exposing a penetration around the escutcheon ring.

6. The quarterly sprinkler service report logs were reviewed at 12:57 p.m. on July 19, 2011. No quarterly sprinkler service inspection had been performed by the contractor for the second quarter (April, May, June) of 2011.

Based on observation on July 18, 2011, the facility did not maintain portable fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings included:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

1. The "K" type portable fire extinguisher located in the kitchen was observed at 11:00 a.m. on July 18, 2011. The extinguisher was mounted on the west wall of the kitchen, but was mounted to be five feet three inches in height. By code, those portable fire extinguishers weighing less than 40 pounds shall be installed no greater than five feet above the floor.

2. The elevator mechanical room in the basement of the hospital was observed at 2:17 p.m. on July 18, 2011. The portable fire extinguisher located in this room had not received an annual service since October of 2009.

Based on observation on July 19, 2011, the facility failed to provide enough combustion and ventilation air at the bottom and top of an enclosure in a confined space. Maintenance staff confirmed that the boiler rate was 300,000 BTU/hour and the water heater was 275,000 BTU. No combustion air can be taken from other rooms in the facility.

Findings include:

In accordance to NFPA 54 - 5.3.3 Equipment Located in Confined Spaces.
(b) All Air from Outdoors. The confined space shall communicate with the outdoors in accordance with method 1 or 2, which follow. The minimum dimension of air openings shall not be less than 3 inches (80 millimeters). Where ducts are used, they shall be of the same cross-sectional area as the free area of the openings to which they connect.
(1) Two permanent openings, one commencing within 12 inches (300 millimeters) of the top and one commencing within 12 inches (300 millimeters) of the bottom, of the enclosure shall be provided. The openings shall communicate directly, or by ducts, with the outdoors or spaces (crawl or attic) that freely communicate with the outdoors.
a. * Where directly communicating with the outdoors or where communicating to the outdoors through vertical ducts, each opening shall have a minimum free area of 1 inch squared per 4000 Btu/hr (550 millimeters squared/kW) of total input rating of all equipment in the enclosure. [See Figures A.5.3.3(b)1a1 and A.5.3.3(b)1a2.]

Make up air for the enclosed space was examined for the second level Hospital boiler room at 9:30 a.m. on July 19, 2011. The surveyor noted that the temperature in the room was very hot and recorded the ambient air temperature at 113 ?Farenheit (F). The surveyor also took readings off of other surfaces (floor, gas piping, furnace shielding, vent piping, fan motors) and recorded temperatures between 125?F and 171?F. A mechanical assist vent was located in the room which provided combustion make up air for the three boilers located in the room. The surveyor could not feel any outside air being provided by the mechanical assist vent tubes at the eight foot level and floor level. The mechanical assist ventilation system in the boiler room did not appear to be functioning properly.

Based on observations, interview with facility staff and review of records available on July 18 and 19, 2011, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semi-annual basis, and that the wet chemical extinguishing system providing fire suppression for the kitchen hood system had been hydrostatically tested in accordance with the standards of NFPA 17A, 1998 Edition.

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.

1. The kitchen hood exhaust system was examined at 11:00 a.m. on July 18, 2011. No documentation was available that the exhaust hood had been inspected and/or cleaned on a semiannual basis.

The following parts of wet chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years: (a) Wet chemical containers; (b) Auxiliary pressure containers and; (c) Hose assemblies per section 5-5 of NFPA 17A.

2. The wet chemical agent container providing protection for the kitchen hood was observed at 11:05 a.m. on July 18, 2011. The cylinder which was located on the west wall of the kitchen near the ceiling, contained no date that a hydrotest had been performed on the cylinder. The cylinder was a stainless steel, wet chemical type container which was installed in 1999 when the facility was opened.

The service reports for the wet chemical system providing fire suppression for the hood were reviewed at 4:05 p.m. on July 18, 2011. There was no indication in the service reports as to the manufacture date of the container or if any hydrostatic testing was required or had been performed. Without such information it could not be ascertained if the requirements of NFPA 17A for testing were being met.

Interview with facility management at the time of the exit revealed that the wet chemical fire suppression system had been installed in 1999 when the building was built and possibly had not been hydrostatically tested since that date.

In accordance with 7-2.1.1 of NFPA 96 (1998 Edition) a placard identifying the use of the "K" extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each "K" portable fire extinguisher in the cooking area.

3. The wet chemical portable fire extinguisher was observed at 11:05 a.m. on July 18, 2011. There was no placard identifying the use of the "K" type extinguisher as a secondary backup means to the automatic fire suppression system in the cooking area.

Based on observations made on July 18 and 19, 2011, the facility failed to provide documentation that numerous window curtains were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The second floor Bronc Room in the Hospital was observed at 4:00 p.m. on July 18, 2011. The curtains in this room were of a darkening variety and did not contain a label attesting that they were either fire resistant or had been treated with a product made for fabrics to render then fire retardant. The facility had no documentation that they had been treated.

Based on observation and record review on July 18, 2011, the facility failed to ensure that the electrical switch and outlet placement was at least five feet from the floor in all medical gas store rooms.

Findings include:

In accordance with 4-3.1.1.2 (11) (d) of NFPA 99 (1999 Edition); ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 meters) above the floor to avoid physical damage.

1. The medical gas store room in the lower level of the Surgery Center was observed at 9:43 a.m. on July 18, 2011. The electrical switch and outlets for the room were not above five feet in elevation to protect them from possible damage during tank deliveries and changes.

2. The medical gas store room on the second level of the Hospital was observed at 4:15 p.m. on July 18, 2011. The electrical switch and outlets for the room were not above five feet in elevation to protect them from possible damage during tank deliveries and changes.

Note: A contractor specializing in Medical Gas and Vacuum systems performed an annual verification on the piped medical gas systems on December 14, 2010. He identified the same observations on his report.

Based on observation and record review on July 18, 2011, the facility failed to keep the Medical Gas and Vacuum Systems in accordance with the requirements in NFPA 99, 1999 edition.

Findings include:

In accordance with Section 4-3.1.2.3 (a) of NFPA 99, (1999 Edition); which states: a shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."

1. The piped Medical Gas Systems were observed in the Medical Gas storeroom in the lower level of the Surgery Center at 9:43 a.m. on July 18, 2011. The following gases were not labeled at the source valve manifolds:

a) Nitrous Oxide
b) Nitrogen
c) Medical Air
d) Oxygen

In accordance with Section 4-3.2.2.4 of NFPA 99, (1999 Edition); which states: all shutoff valves that are not in labeled boxes, such as in the main line, risers, or above suspended ceilings shall be identified by means of durable tags, nameplates, or labels in substance as follows:

CAUTION
MEDICAL SURGICAL VACUUM VALVE
DO NOT CLOSE EXCEPT IN EMERGENCY
THIS VALVE CONTROLS VACUUM TO. . . .

In accordance with Section 4-3.2.2.6 (c) of NFPA 99, (1999 Edition); which states: a shutoff valve shall be installed immediately upstream (on the terminal or inlet side) of the receiver tank in the vicinity of the source equipment.

2. The Vacuum System in the mechanical room of the Surgery Center was observed at 10:44 a.m. on July 18, 2011. The medical vacuum was not properly labeled at the manifold.

Note: A contractor specializing in Medical Gas and Vacuum systems performed an annual verification on the piped medical gas systems on December 14, 2010. He identified the same observations on his report.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and interpretations from 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 (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 per Article 240-4 (b)(3) of NFPA 70. In accordance with UL listing for power strips (relocatable power taps as identified under UL standard 1363 and listings starting with XBYS) there must be a reset or test button identified for the circuit breaker to be reset.

1. The Sump room behind Pharmacy in the lower level of the Hospital had a brown extension cord in use for the injector pump for the sump pump as observed at 2:20 p.m. on July 18, 2011.

2. The Anesthesia Department office on the first floor of the Surgical Center had two extension cords being used in the place of permanent wiring as observed at 7:10 a.m. on July 19, 2011.

3. The Business office on the first floor of the Surgical Center had two surge cords plugged in series under one of the office desks as observed at 7:14 a.m. on July 19, 2011. Also, at this same desk, there was a wall heater and Christmas wrap had been placed in direct contact with the heater.

4. The Break room in the lower level of the Surgical Center had a microwave oven plugged directly into a surge cord as observed at 8:42 a.m. on July 19, 2011.

In accordance with Article 110-13(a) of NFPA 70 (1999 edition) electrical equipment shall be firmly secured to the surface on which it is mounted.

5. The Doctor's Lounge on the main level of the Surgical Center had a surge cord plugged into the north wall which was dangling on the cord and not supported properly.

In accordance with NFPA 70, 1999 Edition and specifically section 230-50 Protection of Open Conductors and Cables Against Damage ? Above Ground, service-entrance conductors installed above ground shall be protected against physical damage as specified in (a) or (b).
(a) Service Cables. Service cables, where subject to physical damage, shall be protected by any of the following:
1. Rigid metal conduit
2. Intermediate metal conduit
3. Rigid nonmetallic conduit suitable for the location
4. Electrical metallic tubing
5. Other approved means
(b) Other than Service Cable. Individual open conductors and cables other than service cables shall not be installed within 10 ft (3.05 m) of grade level or where exposed to physical damage.

6. The Ball room in the lower level of the Hospital had Romex wire which had been installed without using conduit as observed at 2:30 p.m. on July 18, 2011.

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.

7. The south wall of the Data room in the lower level of the Surgical Center had a junction box with its cover missing as observed at 1:07 a.m. on July 18, 2011.

8. The smoke barrier wall above the smoke barrier doors next to MRI and the northeast stairwell had a junction box cover missing directly above the ceiling tile as observed at 11:00 a.m. on July 19, 2011.

Based on observations made on July 18 and 19, 2011, 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, Life Safety Code (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 set of fire doors between PAC-U and the reception waiting area of the ground floor of the Surgery Center were exercised at 7:55 a.m. on July 19, 2011. The set of fire doors failed to latch when exercised on three tries.

2. The sprinkler riser room, which borders the fire wall between PAC-U and the waiting area of the ground floor, was observed at 8:14 a.m. on July 19, 2011. The corridor wall had a one-half inch conduit which was not sealed.

3. The 1-hour rated set of fire doors between the corridor and the elevator on second floor of the hospital were exercised at 9:07 a.m. on July 19, 2011. The doors failed to latch when exercised on three different tries.

4. The short hall leading to Central Montana Medical Office Building (MOB), near the main entrance and along the west side of the building, was observed at 10:05 a.m. on July 19, 2011. The following unsealed penetrations were found:

a) One four inch penetration was found in the west fire wall above the ceiling tile, and

b) One penetration was found in the south wall above the door leading into MOB for a cable.

5. The fire wall between PAC-U and the waiting area was observed at 10:12 a.m. on July 19, 2011. The fire wall above the set of doors leading into PAC-U had some of the fire tape peeling off, as there was no joint compound applied over the tape.

Based on observations made during a survey of July 18 and 19, 2011, it has been determined that the facility did not maintain the fire resistive rating of wall and ceiling assemblies.

Findings include:

1. The air-handling room in the south west corner of the basement of the Surgical Center was observed at 11:15 a.m. on July 18, 2011. Two ceiling tiles were out of place in this room.

2. The Data room and the Conference room, in the basement of the Surgical Center, were observed at 1:00 p.m. on July 18, 2011.

a) There was five penetrations in the wall which separates the Data room from the Conference room, for communication cable.

b) There were three penetrations in the south wall of the Data room for communication wiring at conduits.

3. The MRI Data room located in the basement of the Surgical Center was observed at 1:18 p.m. on July 18, 2011. Six ceiling tiles were out of place in this room.

4. The Break room in the basement of the Surgical Center was observed at 1:57 p.m. on July 18, 2011. There were two Internet cords through the ceiling tile preventing the tiles from laying flat in the suspended grid.

5. The Accounting office off of the Break room in the basement of the Surgical Center was observed at 2:00 p.m. on July 18, 2011. There was one Internet cord through the ceiling tile preventing the tiles from laying flat in the suspended grid.

6. The Insurance Follow-up office off of the Break room in the basement of the Surgical Center was observed at 2:01 p.m. on July 18, 2011. There was one Internet cord through the ceiling tile preventing the tiles from laying flat in the suspended grid.

7. The Soiled Utility room on the second floor of the Hospital was observed at 9:20 a.m. on July 19, 2011. There was a ceiling tile missing in this room.

8. The short hall leading to MOB, on the west side main entrance to the Hospital was observed at 10:10 a.m. on July 19, 2011. There was one penetration in the north wall above the ceiling tile near the two steps leading to the Data Room for MOB.

9. The Sterile store room in the basement of the Surgical Center was observed at 2:00 p.m. on July 18, 2011. A speaker had been installed above the ceiling tile, and a two inch round hole had been cut in the tile and was not sealed.

Based on observations which were made on July 18 and 19, 2011, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

1. The Ball room in the lower level of the Surgical Hospital was observed at 2:31 p.m. on July 18, 2011. There was a penetration of the east corridor wall at the midpoint area where a one-half inch conduit was not properly sealed.

2. The ground floor Electrical room of the Hospital was observed at 8:20 a.m. on July 19, 2011. There was a three-quarter inch conduit through the north wall of the Electrical room which was not sealed.

Based on observation on July 18 & 19, 2011, the facility did not ensure all exit corridor doors were free from impediments that prevent them being held open by means not acceptable to the Life Safety Code.

Findings included:

In accordance with 19.3.6.3.3 of the Life Safety Code hold-open devices that release when the door is pushed or pulled shall be permitted (this does not apply to hazardous area protection). Doors can not be blocked open by furniture, door stops, chocks or devices that necessitate manual releasing action to close the door. Further guidance from Annex A and specifically section A.19.3.6.3.3 states that 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. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

1. The Internet Technology (IT) office corridor door was blocked open with a wedge as observed at 2:49 p.m. on July 18, 2011.

2. The corridor door to the Staff Supply storeroom on the second level of the Hospital was blocked open with a wedge as observed at 9:22 a.m. on July 19, 2011.

Based on observations made on July 18 and 19, 2011, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

The findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The north side storeroom in the basement of the Surgery Center was observed at 12:50 p.m. on July 18, 2011. One vent tube through the ceiling to the level above was not properly sealed with a material rated for fire resistive construction.

2. The Tool Crib (elevator shaft) in the lower level of the Surgery Center was observed at 2:08 p.m. on July 18, 2011. The door to the shaft was blocked open with a wedge.

3. The Ball room in the basement of the Hospital was observed at 2:30 p.m. on July 18, 2011. The four foot by five foot shaft leading to the level above which is located directly above the entrance door to the room was not fire taped.

4. The Sump room in the basement of the Hospital was observed at 2:40 p.m. on July 18, 2011. The ceiling along the west wall had three penetrations through to the deck above. All were conduits which were not properly sealed with a material capable of maintaining the fire resistance of the barrier.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The Sump room in the basement of the Hospital was observed at 2:38 p.m. on July 18, 2011.

a) There were two penetration through the southeast corner of the west wall near the ceiling which were not sealed.

b) There were two penetrations in the north wall for conduit which contained communication cable which were not sealed.

2. The set of smoke barrier doors between rooms 105 and 106 of the Hospital were exercised at 8:30 a.m. on July 19, 2011. The doors failed to latch when exercised on three different tries.

3. The set of smoke barrier doors between the Nursing Supervisors office and the exit corridor were exercised at 8:40 a.m. on July 19, 2011. The doors failed to latch when exercised on three different tries.

4. The smoke wall above the smoke barrier doors next to MRI on first floor of the Surgical Center was observed at 10:15 a.m. on July 19, 2011.

a) Two 3/4 inch water pipes were not sealed above the smoke barrier doors

b) There was also a one inch penetration in the wall which was not sealed.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain the fire rated assemblies protecting smoke compartments, and assure that smoke barrier doors closed flush with each other at the meeting edges to prevent the passage of smoke.

The findings include:

1. Smoke barrier doors protecting smoke compartments were checked to see if the assemblies prevented the passage of smoke between compartments. The 1 hour rated smoke barrier door between the south Nursing Station and Medication Room on the main level of the Hospital was exercised at 8:42 a.m. on July 19, 2011. The smoke barrier door failed to latch properly when exercised on three different tries.

2. The set of 1-hour rated smoke barrier doors between the Medical Office Building (MOB) and the ground floor women's restroom was exercised at 9:10 a.m. on July 19, 2011. The set of smoke barrier doors failed to latch when exercised during three different tries.

3. The smoke barrier wall which separates the MRI area in the basement of the Hospital was observed at 1:50 p.m. on July 19, 2011. The large lead door in the smoke barrier wall of MRI was not self-closing.

Based on observation, the facility failed to provide self-closing doors on all hazardous areas and to keep all hazardous areas properly protected.

Findings include:

In accordance with NFPA 101 and section 19.3.2.1 Hazardous Areas, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Section 8.4.1.3 of NFPA 101, Life Safety Code states: Doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

1. The soiled laundry room in the basement of the Surgical Center was observed at 12:45 p.m. on July 18, 2011. The corridor door to this room failed to latch when exercised on three different tries.

2. The storage room along the north side of the basement of the Surgical Center was observed at 12:55 p.m. on July 18, 2011. A vent tube through the wall was not sealed in this room.

3. The MRI Data room in the lower level of the Surgical Center was observed at 1:15 p.m. on July 18, 2011. The corridor door to this store room was blocked open with a dust pan.

4. The boiler room in the lower level of the Surgical Center was observed at 1:20 p.m. on July 18, 2011.

a) The north wall had a penetration of a one-half inch conduit for electrical wiring which was not sealed.

b) The west wall had two penetrations which were not sealed, one was a hot water line in the north west corner and the remaining was a one-half inch conduit for electrical wiring above the electrical cabinet labeled Air Handling Unit (AHU) #1.

5. The door to the soiled utility room in the rear of PAC-U was not self-closing as observed at 7:55 a.m. on July 19, 2011.

6. The boiler room on the second floor of the Hospital was observed at 9:32 a.m. on July 19, 2011. The ceiling of this room is not covered with joint compound over all screws and sheet rock seams to complete the fire resistance of the ceiling.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain exit stair gates to prevent patients, staff, and members of the public from going to the lower level in an exit stairway.

According to Section 7.7.3 of NFPA 101, stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Findings include:

1. The southwest stairway of the Hospital building was reviewed at 8:17 a.m. on July 19, 2011. There was no gate in the stairway preventing patients, staff, and members of the public from going to the lower level during emergency evacuation.

2. The northeast stairway of the Hospital building was reviewed at 10:30 a.m. on July 19, 2011. There was no gate in the stairway preventing patients, staff, and members of the public from going to the lower level during emergency evacuation.

Based on review of battery powered emergency light fixture testing logs and interview with maintenance staff on July 18, 2011, the facility did not ensure that the required 30 second monthly and 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 surveyor asked to review the logs/records for the battery powered emergency light fixtures at 11:05 a.m. on July 18, 2011.

An interview with staff member A at this same time revealed that testing of the battery pack emergency lighting for 2010 -2011 was not done. When questioned about the monthly and annual testing, staff member A indicated the facility did not know about the requirement for 30 second monthly and 90 minute annual testing of emergency battery pack lighting fixtures. Hence, there was no record. He also stated that the only fixtures he was testing were located in the operating rooms and recovery rooms, and that he was performing about a 15 second monthly test of the fixtures. He also stated that several batteries had to be replaced as they would no longer retain a charge.

Twenty six light fixtures were tested during the survey process, we may have missed one or two along the way, as they did not know how many units were installed in the two buildings.

2. The battery powered emergency light fixture located in the elevator mechanical room in the basement of the Surgery Center was checked at 2:05 p.m. on July 18, 2011. The fixture failed to illuminate when tested.

Based on staff interview and review of the fire drill reports made on July 18, 2011, the facility failed to assure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift.

The findings include:

In accordance with Section 19.7.1.2 of NFPA 101, Life Safety Code; which states: fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms.

The fire drill reports were reviewed at 11:00 a.m. on July 18, 2011. No written documentation was found that a fire drills had been conducted on the following:

a.) night shift (7:00 p.m. to 7:00 a.m.) during the third quarter (July, August, September) of 2010,
b.) day shift (7:00 a.m. to 7:00 p.m.) during the fourth quarter (October, November, December) of 2010,
c.) night shift (7:00 p.m. to 7:00 a.m.) during the fourth quarter (October, November, December) of 2010, and
d.) night shift (7:00 p.m. to 7:00 a.m.) during the first quarter (January, February, March) of 2011.

Interview with facility staff at the time of the exit revealed that staff thought that they could perform drills at the shift change and catch both shifts. Three out of the four drills which were completed in the past year were completed at the shift change (0700 to 0730).

Based on review of the fire alarm service reports on July 18, 2011, the facility did not ensure that sensitivity testing results were available for the years 2008 through 2011.

Findings included:

Smoke detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per 7-3.2.1 of NFPA 72, 1999 Edition. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range or 4 percent obscuration light gray smoke, if not marked, the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. It is being required by the Centers for Medicare and Medicaid Services (CMS), as the authority having jurisdiction, that those systems that automatically monitor sensitivity shall have a paper printout available verifying the calibration of each detector.

The fire alarm service reports were reviewed at the facility on July 18, 2011. There was no written documentation or report that indicated the contractor had printed the sensitivity testing results in 2011 or previously. Hard copy documentation of smoke alarm sensitivities must be available in the facility when requested.

Based on observation on July 18 & 19, 2011, the facility failed to keep the proper number of spare heads in the spare head cabinets in the Hospital and Surgical Center sprinkler riser rooms, monitor fire suppression systems, and maintain sprinkler system components.

Findings include:

In accordance with Section 2-2.1.3 of NFPA 25, 1998 edition, the supply of spare sprinklers shall be inspected annually for the following: (a) The proper number and type of sprinklers (b) A sprinkler wrench for each type of sprinkler.

In accordance with Section 2-4.1.4 of NFPA 25, 1998 Edition, a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

1. The spare head cabinet sprinkler riser room of the Hospital was observed at 9:52 a.m. on July 18, 2011. The cabinet lacked a minimum of six heads for each type of sprinkler head that the facility may have. The Code requires the facility to have at least six spare heads of each type sprinkler which the facility may have.

2. The spare head cabinet in the sprinkler riser room of the Surgical Center was observed at 9:04 a.m. on July 19, 2011. The cabinet lacked a minimum of six heads for each type of sprinkler head that the facility may have. The Code requires the facility to have at least six spare heads of each type sprinkler which the facility may have.

3. The Bulk storeroom in the basement of the Surgical Center was observed at 12:57 p.m. on July 18, 2011. There were two sprinkler heads missing escutcheon rings.

4. The MRI Data room was observed at 1:15 p.m. on July 18, 2011. The (Reliable Model H Prepak) fire suppression system which serves this room was in alarm mode, indicating that there was low air pressure in zone four of the system. An audible and visible alarm was being indicated on the digital readout board, but no one that the surveyor spoke to was aware of the alarm. The corridor door to this room was blocked open, ceiling tiles had been taken out but no one was working on the system. This surveyor checked the room on three different occasions that same afternoon. The system was in alarm mode, all afternoon, with the corridor door being blocked open and ceiling tiles taken out. At 4:15 p.m. the surveyor reported the findings to personnel in MRI and they said that they would contact the contracted authority for the system.

5. The closet in the Case Management office on the main level of the Surgical Center was observed at 9:02 a.m. on July 19, 2011. An escutcheon ring was down from the ceiling tile approximately one half inch, exposing a penetration around the escutcheon ring.

6. The quarterly sprinkler service report logs were reviewed at 12:57 p.m. on July 19, 2011. No quarterly sprinkler service inspection had been performed by the contractor for the second quarter (April, May, June) of 2011.

Based on observation on July 18, 2011, the facility did not maintain portable fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings included:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

1. The "K" type portable fire extinguisher located in the kitchen was observed at 11:00 a.m. on July 18, 2011. The extinguisher was mounted on the west wall of the kitchen, but was mounted to be five feet three inches in height. By code, those portable fire extinguishers weighing less than 40 pounds shall be installed no greater than five feet above the floor.

2. The elevator mechanical room in the basement of the hospital was observed at 2:17 p.m. on July 18, 2011. The portable fire extinguisher located in this room had not received an annual service since October of 2009.

Based on observation on July 19, 2011, the facility failed to provide enough combustion and ventilation air at the bottom and top of an enclosure in a confined space. Maintenance staff confirmed that the boiler rate was 300,000 BTU/hour and the water heater was 275,000 BTU. No combustion air can be taken from other rooms in the facility.

Findings include:

In accordance to NFPA 54 - 5.3.3 Equipment Located in Confined Spaces.
(b) All Air from Outdoors. The confined space shall communicate with the outdoors in accordance with method 1 or 2, which follow. The minimum dimension of air openings shall not be less than 3 inches (80 millimeters). Where ducts are used, they shall be of the same cross-sectional area as the free area of the openings to which they connect.
(1) Two permanent openings, one commencing within 12 inches (300 millimeters) of the top and one commencing within 12 inches (300 millimeters) of the bottom, of the enclosure shall be provided. The openings shall communicate directly, or by ducts, with the outdoors or spaces (crawl or attic) that freely communicate with the outdoors.
a. * Where directly communicating with the outdoors or where communicating to the outdoors through vertical ducts, each opening shall have a minimum free area of 1 inch squared per 4000 Btu/hr (550 millimeters squared/kW) of total input rating of all equipment in the enclosure. [See Figures A.5.3.3(b)1a1 and A.5.3.3(b)1a2.]

Make up air for the enclosed space was examined for the second level Hospital boiler room at 9:30 a.m. on July 19, 2011. The surveyor noted that the temperature in the room was very hot and recorded the ambient air temperature at 113 ?Farenheit (F). The surveyor also took readings off of other surfaces (floor, gas piping, furnace shielding, vent piping, fan motors) and recorded temperatures between 125?F and 171?F. A mechanical assist vent was located in the room which provided combustion make up air for the three boilers located in the room. The surveyor could not feel any outside air being provided by the mechanical assist vent tubes at the eight foot level and floor level. The mechanical assist ventilation system in the boiler room did not appear to be functioning properly.

Based on observations, interview with facility staff and review of records available on July 18 and 19, 2011, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semi-annual basis, and that the wet chemical extinguishing system providing fire suppression for the kitchen hood system had been hydrostatically tested in accordance with the standards of NFPA 17A, 1998 Edition.

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.

1. The kitchen hood exhaust system was examined at 11:00 a.m. on July 18, 2011. No documentation was available that the exhaust hood had been inspected and/or cleaned on a semiannual basis.

The following parts of wet chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years: (a) Wet chemical containers; (b) Auxiliary pressure containers and; (c) Hose assemblies per section 5-5 of NFPA 17A.

2. The wet chemical agent container providing protection for the kitchen hood was observed at 11:05 a.m. on July 18, 2011. The cylinder which was located on the west wall of the kitchen near the ceiling, contained no date that a hydrotest had been performed on the cylinder. The cylinder was a stainless steel, wet chemical type container which was installed in 1999 when the facility was opened.

The service reports for the wet chemical system providing fire suppression for the hood were reviewed at 4:05 p.m. on July 18, 2011. There was no indication in the service reports as to the manufacture date of the container or if any hydrostatic testing was required or had been performed. Without such information it could not be ascertained if the requirements of NFPA 17A for testing were being met.

Interview with facility management at the time of the exit revealed that the wet chemical fire suppression system had been installed in 1999 when the building was built and possibly had not been hydrostatically tested since that date.

In accordance with 7-2.1.1 of NFPA 96 (1998 Edition) a placard identifying the use of the "K" extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each "K" portable fire extinguisher in the cooking area.

3. The wet chemical portable fire extinguisher was observed at 11:05 a.m. on July 18, 2011. There was no placard identifying the use of the "K" type extinguisher as a secondary backup means to the automatic fire suppression system in the cooking area.

Based on observations made on July 18 and 19, 2011, the facility failed to provide documentation that numerous window curtains were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The second floor Bronc Room in the Hospital was observed at 4:00 p.m. on July 18, 2011. The curtains in this room were of a darkening variety and did not contain a label attesting that they were either fire resistant or had been treated with a product made for fabrics to render then fire retardant. The facility had no documentation that they had been treated.

Based on observation and record review on July 18, 2011, the facility failed to ensure that the electrical switch and outlet placement was at least five feet from the floor in all medical gas store rooms.

Findings include:

In accordance with 4-3.1.1.2 (11) (d) of NFPA 99 (1999 Edition); ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 meters) above the floor to avoid physical damage.

1. The medical gas store room in the lower level of the Surgery Center was observed at 9:43 a.m. on July 18, 2011. The electrical switch and outlets for the room were not above five feet in elevation to protect them from possible damage during tank deliveries and changes.

2. The medical gas store room on the second level of the Hospital was observed at 4:15 p.m. on July 18, 2011. The electrical switch and outlets for the room were not above five feet in elevation to protect them from possible damage during tank deliveries and changes.

Note: A contractor specializing in Medical Gas and Vacuum systems performed an annual verification on the piped medical gas systems on December 14, 2010. He identified the same observations on his report.

Based on observation and record review on July 18, 2011, the facility failed to keep the Medical Gas and Vacuum Systems in accordance with the requirements in NFPA 99, 1999 edition.

Findings include:

In accordance with Section 4-3.1.2.3 (a) of NFPA 99, (1999 Edition); which states: a shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."

1. The piped Medical Gas Systems were observed in the Medical Gas storeroom in the lower level of the Surgery Center at 9:43 a.m. on July 18, 2011. The following gases were not labeled at the source valve manifolds:

a) Nitrous Oxide
b) Nitrogen
c) Medical Air
d) Oxygen

In accordance with Section 4-3.2.2.4 of NFPA 99, (1999 Edition); which states: all shutoff valves that are not in labeled boxes, such as in the main line, risers, or above suspended ceilings shall be identified by means of durable tags, nameplates, or labels in substance as follows:

CAUTION
MEDICAL SURGICAL VACUUM VALVE
DO NOT CLOSE EXCEPT IN EMERGENCY
THIS VALVE CONTROLS VACUUM TO. . . .

In accordance with Section 4-3.2.2.6 (c) of NFPA 99, (1999 Edition); which states: a shutoff valve shall be installed immediately upstream (on the terminal or inlet side) of the receiver tank in the vicinity of the source equipment.

2. The Vacuum System in the mechanical room of the Surgery Center was observed at 10:44 a.m. on July 18, 2011. The medical vacuum was not properly labeled at the manifold.

Note: A contractor specializing in Medical Gas and Vacuum systems performed an annual verification on the piped medical gas systems on December 14, 2010. He identified the same observations on his report.

Based on observations made on July 18 and 19, 2011, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and interpretations from 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 (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 per Article 240-4 (b)(3) of NFPA 70. In accordance with UL listing for power strips (relocatable power taps as identified under UL standard 1363 and listings starting with XBYS) there must be a reset or test button identified for the circuit breaker to be reset.

1. The Sump room behind Pharmacy in the lower level of the Hospital had a brown extension cord in use for the injector pump for the sump pump as observed at 2:20 p.m. on July 18, 2011.

2. The Anesthesia Department office on the first floor of the Surgical Center had two extension cords being used in the place of permanent wiring as observed at 7:10 a.m. on July 19, 2011.

3. The Business office on the first floor of the Surgical Center had two surge cords plugged in series under one of the office desks as observed at 7:14 a.m. on July 19, 2011. Also, at this same desk, there was a wall heater and Christmas wrap had been placed in direct contact with the heater.

4. The Break room in the lower level of the Surgical Center had a microwave oven plugged directly into a surge cord as observed at 8:42 a.m. on July 19, 2011.

In accordance with Article 110-13(a) of NFPA 70 (1999 edition) electrical equipment shall be firmly secured to the surface on which it is mounted.

5. The Doctor's Lounge on the main level of the Surgical Center had a surge cord plugged into the north wall which was dangling on the cord and not supported properly.

In accordance with NFPA 70, 1999 Edition and specifically section 230-50 Protection of Open Conductors and Cables Against Damage ? Above Ground, service-entrance conductors installed above ground shall be protected against physical damage as specified in (a) or (b).
(a) Service Cables. Service cables, where subject to physical damage, shall be protected by any of the following:
1. Rigid metal conduit
2. Intermediate metal conduit
3. Rigid nonmetallic conduit suitable for the location
4. Electrical metallic tubing
5. Other approved means
(b) Other than Service Cable. Individual open conductors and cables other than service cables shall not be installed within 10 ft (3.05 m) of grade level or where exposed to physical damage.

6. The Ball room in the lower level of the Hospital had Romex wire which had been installed without using conduit as observed at 2:30 p.m. on July 18, 2011.

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.

7. The south wall of the Data room in the lower level of the Surgical Center had a junction box with its cover missing as observed at 1:07 a.m. on July 18, 2011.

8. The smoke barrier wall above the smoke barrier doors next to MRI and the northeast stairwell had a junction box cover missing directly above the ceiling tile as observed at 11:00 a.m. on July 19, 2011.