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Based on observations made on April 10, 2013, the facility failed to provide for protection of a communicating opening in a two-hour fire barrier wall between a nonsprinklered business occupancy and a sprinklered health care occupancy (Critical Access Hospital). This deficiency affects two of two smoke compartments on the CAH building.

The findings include:

Communicating openings in dividing fire barriers shall be permitted only in corridors and shall be protected by approved self-closing fire doors (see also section 8.2) per section 19.1.1.4.2 of the Life Safety Code. Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed per section 8.2.3.2.1 of the Life Safety Code (LSC) and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1 of the LSC. In any building of low or ordinary hazard contents, including healthcare occupancies, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing per section 7.2.1.8.2 of the LSC, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

In accordance with NFPA 101 and Section 7.10.8.1, any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

The facility adjoins a Clinic that was subject to remodeling and an addition in 2009. This construction phase revised the position of the two-hour barrier between the Critical Access Hospital (CAH) as a completely sprinklered healthcare occupancy and the nonsprinklered Clinic building which is a business occupancy. The revised two-hour barrier was examined beginning at 1:46 p.m. on April 10, 2013. The two-hour wall, previous to the construction, had a communicating opening protected by a swinging 1.5 hour rated fire door assembly. With the construction phase of the project, a new rolling (vertical) metal clad fire door with approved frame was installed in the ramp corridor leading from the CAH to the Clinic. Upon testing of the rolling fire door, it was determined that the manual release device, now in place for the door, required that a ceiling tile be removed to access the release device. This type of action did not instantly release the door in case of emergency. The door could not readily be closed without the use of a ladder and removal of ceiling tiles. No smoke detectors were located within 5 feet on either side of the rolling door to detect the movement of smoke through the opening to automatically release the hold-open mechanism of the fire door and close it. Loss of power would not close the fire door since the release device was not interconnected to the power system. Furthermore, since this type of fire door cannot be used as a means of egress during a fire emergency (it is a non-swinging door), the ramp/corridor in which it is situated would become a dead end requiring a sign at the entry way to the ramp from the CAH signifying that it is NO EXIT per NFPA 101 7.10.8.1. Such a sign was not in place at the time of the survey. No documentation was available for review as to the installation instructions as may concern audible or visual warnings of the door closing, interconnection to the fire alarm system or a means (such as a keyed control) for mechanical opening of the door upon reset of the fire alarm system or smoke detectors.

Based on observations made on April 10, 2013, the facility failed to maintain the fire and smoke resistance rating of interior wall assemblies. These deficiencies affected one of three smoke compartments in the former long term care area and one of two smoke compartments in the basement area which is only accessed by staff.

The findings include:

1. The dining/activity room suite in the A wing/smoke compartment was toured during the survey. This was the only dining/activity room on this wing. Mechanical room #4 is accessed off of this suite and was examined at 11:05 a.m. on April 10, 2013. A flexible 6-inch conduit penetrates the west wall of the mechanical room. The opening around the flexible conduit in the wall assembly was not properly sealed with a flange or other material to maintain the fire and smoke resistance rating of the assembly.

2. The portion of the basement area located under the Administrative offices was toured during the survey. A storage room housing large amounts of combustible materials adjacent to the Maintenance office in this basement area was examined at 2:40 p.m. on April 10, 2013. Directly above the corridor door into this storage room were located conduit and wiring that penetrated the wall assembly. Although sealed at one time, the material used for such purpose had deteriorated with the result that the penetrations were not properly sealed to maintain the fire and smoke resistance rating of the assembly.

Based upon observations made on April 10, 2013, the facility failed to assure that smoke barrier doors closed tightly to resist the passage of smoke and failed to assure that smoke barrier doors within a means of egress swung open without impediment and did not bind on the door frame. These deficiencies affected three of three smoke compartments of the former nursing home building.

The findings include:

1. The set of smoke barrier doors on the A wing/smoke compartment were exercised at 10:49 a.m. on April 10, 2013. These doors were located adjacent to room A-1. The doors were supplied with a gasket material at the meeting edges to restrict the passage of smoke. The gasket material did not completely cover the gap or opening between the doors when exercised.

2. The set of smoke barrier doors on the B wing/smoke compartment were exercised at 3:49 p.m. on April 10, 2013. These doors were located adjacent to room B-1. The south door of this set was observed to be binding on the frame of the door inhibiting it from opening with at least 15 pounds of pressure so as to be used as a means of egress from the B wing/smoke compartment.

Based on observations made on April 10, 2013, the facility failed to assure that a corridor door to a storage room exceeding 50 square feet in size and housing large amounts of combustibles was provided with a self-closure device and failed to prevent the storage of combustible materials in an open crawl space in a building of Type V (111) construction. This deficiency affected one of three smoke compartments in the long term care building and one of two smoke compartments in the basement which is only accessed by staff.

The findings include:

1. An ex-isolation room, located between rooms B-1 and B-3 in the B wing smoke compartment, was examined at 10:17 a.m. on April 10, 2013. This configuration of an ex-isolation room is the only one in this smoke compartment. The room was presently being used as a storage room for large amounts of combustibles and exceeded 50 square feet in size. The entire building was protected by the automatic sprinkler system and the corridor door must have at least a self-closure device. No self-closure device was in place on the corridor door. Note: Communicating doors leading to rooms B-1 and B-3 were not in use and locked in place from this storage room at the time of the survey but would require a self-closure if they were to be used once again as openings.

2. The crawl space under the B wing smoke compartment of the building was examined at 3:21 p.m. on April 10, 2013. The crawl space was sprinklered due to the wood floor/beam construction in that area. Insulation, which has the capability to smolder and produce smoke during a fire, was found to be stored in the open crawl space and not separated by one hour construction from the crawl space.

Based on review of fire alarm service and test reports on April 10, 2013, the facility failed to provide documentation that the fire alarm system was installed and certified in accordance with NFPA 72, 1999 Edition. This deficiency affects all portions of both buildings.

The findings include:

All new fire alarm systems shall be inspected and tested in accordance with the requirements of Chapter 7 per section 7-1.6.1 of NFPA 72, 1999 Edition. After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner's designated representative per section 7-5.1 of NFPA 72. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction (AHJ). Paper or electronic media shall be permitted

The fire alarm service and test reports were reviewed at the facility on April 10, 2013. The fire alarm system serves the entire building. A new Fire Alarm Control Panel (FACP) was installed in 2009 after the last survey of January 20, 2009. The new panel is a Simplex model 4100U addressable panel. Since the facility utilized a majority of the existing smoke detectors to interface with the new panel it shows alarms by zones and also identifies a few smoke detectors by an address. The installation of the FACP required a new certificate of completion that must be kept by the owner for the life of the system and available for examination by the State Agency (AHJ). No certificate of completion was available for review at the time of the survey.

Based on review of the fire alarm and smoke detection service and test records on April 10, 2013, the facility failed to assure that sensitivity tests were conducted in accordance with NFPA 72, 1999 Edition. This deficiency affects all portions of both buildings.

The findings include:

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per section 7-3.2.1 of NFPA 72. 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 Centers for Medicare and Medicaid Services, 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 and smoke detector service and test records were reviewed at the facility on April 10, 2013. The facility has smoke detectors throughout the corridor system of all the smoke compartments and additionally has duct detectors and several individual rooms with smoke detectors. A new Fire Alarm Control Panel (FACP) was installed in 2009 with the retention of many of the existing smoke detectors being interfaced to the new panel. The last documented sensitivity testing recorded by previous surveys occurred on November 9, 2004 and the five year sensitivity tests was due before the end of 2009. With the installation of a new FACP all of the detectors were subject to sensitivity testing upon completion of the new installation and within one year thereafter. No documentation was available that a sensitivity test was conducted on the smoke detectors after the installation of the new FACP or in the subsequent years of 2010, 2011, 2012 or thus far in 2013.

Based on review of the service reports for the automatic fire sprinkler system and on observations made on April 10, 2013, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13, 1999 Edition and NFPA 25, 1998 Edition. These deficiencies affect all portions of both buildings.



The findings include:

Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall per section 2-2.1.1 of NFPA 25. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in improper orientation.

1. The open lounge at the west end of the B wing/smoke compartment was examined at 10:37 a.m. on April 10, 2013. This was the only open area to the corridor in this wing and the opening to the lounge was directly observable from the nurse's station. The sprinkler head in the lounge located near the corridor opening was observed to have a coating of material on it that may be the result of a leakage condition.

2. The six rooms that open onto the west corridor of the Acute Care smoke compartment were examined during the course of the survey. One of these rooms, being a janitor's closet, was observed at 12:50 p.m. on April 10, 2013, to have a sprinkler head coated with foreign material.

3. Four patient rooms on the south corridor of the Acute Care smoke compartment were examined during the course of the survey. One of these rooms, being room 4, was observed at 12:52 p.m. on April 10, 2013, to have a sprinkler head coated with foreign material.

4. The Medical Records suite located on the north corridor of the Administrative/Medical Record/Physical Therapy smoke compartment was examined at 2:12 p.m. on April 10, 2013. A sprinkler head in the main room of the suite was observed to have a coating of material on it that may be the result of a leakage condition.

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per section 3-2.7.2 of NFPA 13 and per UL listing (VNUV guidelines) must be flush with the surface on which they are mounted.

5. The Laboratory located in the Acute Care smoke compartment of the building was examined at 12:41 p.m. on April 10, 2013. This was the only Laboratory located in the building. Two of the ceiling sprinklers in the main Laboratory room were pendent type extending through the suspended tile ceiling assembly. The escutcheons for these two sprinklers did not fully cover the holes for the sprinklers in the ceiling tiles.

Check valves, detector check valves, and backflow preventers, that are installed in the water supply piping system shall be inspected and maintained so that they do not impede the flow of water and fire main pressure in accordance with Chapter 9 of NFPA 25 per section 8-2.8 of NFPA 25. Check valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition per section 9-4.2.1 of NFPA 25. All backflow preventers installed in fire protection system piping shall be tested annually per one of two test methods noted in section 9-6.2.1 of NFPA 25.

6. The sprinkler riser located in the basement of the facility, which provides protection for the entire facility, was examined at 2:32 p.m. on April 10, 2013. The riser was provided with what appeared to be a double check valve assembly. In reviewing the sprinkler report for March 4, 2013, it was noted by the licensed and endorsed contractor that this was a "backflow" device. Dependent upon the actual use of the valve in place, there was no documentation available that it had been tested on either an annual basis for a backflow preventer or on a five year basis for a check valve installation.

Based on observations and review of service records or logs on April 10, 2013, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis. This deficiency affects one of two smoke compartments in the CAH building.

The findings include:

Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal 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. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire 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. It shall also indicate areas not cleaned per 8-3.1.2 of NFPA 96.

The service records or logs were reviewed at the facility on April 10, 2013 and the kitchen hood exhaust system was examined at 11:24 a.m. on April 10, 2013. No documentation was available that the kitchen hood system had been inspected and/or cleaned in the preceding six month period (semiannually) by a properly trained, qualified, and certified company or person(s).

Based on observations made on April 10, 2013, 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 or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies affect all of the smoke compartments for both buildings.

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.

1. Twelve resident rooms were examined in the B wing/smoke compartment during the course of the survey for electrical conformance. A white household type extension cord, without built-in circuit breaker protection, was in use for a TV in room B-6 as observed at 10:30 a.m. on April 10, 2013.

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 K located in the kitchen suite was examined at 11:28 p.m. on April 10, 2013. The listings on the panel board breaker identification card did not correspond exactly to the breakers in use and several breakers did not have a number that related to their listings. An example was breaker numbers 14 and 16 with 16 not being properly identified as to it's use.

3. One of the two electrical panel boards located in the basement room housing the transfer switch for the generator was examined at 3:10 p.m. on April 10, 2013. One of the breakers in this panel board was identified with a red dot signifying that it supplied the power for the Fire Alarm Control Panel (FACP). However, since the new FACP installed in 2009 listed a different panel and breaker other than the one noted, the listings for the panel board in question must be updated to reflect the most current identification.

Based on observations made on April 10, 2013, the facility failed to provide for protection of a communicating opening in a two-hour fire barrier wall between a nonsprinklered business occupancy and a sprinklered health care occupancy (Critical Access Hospital). This deficiency affects two of two smoke compartments on the CAH building.

The findings include:

Communicating openings in dividing fire barriers shall be permitted only in corridors and shall be protected by approved self-closing fire doors (see also section 8.2) per section 19.1.1.4.2 of the Life Safety Code. Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed per section 8.2.3.2.1 of the Life Safety Code (LSC) and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1 of the LSC. In any building of low or ordinary hazard contents, including healthcare occupancies, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing per section 7.2.1.8.2 of the LSC, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

In accordance with NFPA 101 and Section 7.10.8.1, any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

The facility adjoins a Clinic that was subject to remodeling and an addition in 2009. This construction phase revised the position of the two-hour barrier between the Critical Access Hospital (CAH) as a completely sprinklered healthcare occupancy and the nonsprinklered Clinic building which is a business occupancy. The revised two-hour barrier was examined beginning at 1:46 p.m. on April 10, 2013. The two-hour wall, previous to the construction, had a communicating opening protected by a swinging 1.5 hour rated fire door assembly. With the construction phase of the project, a new rolling (vertical) metal clad fire door with approved frame was installed in the ramp corridor leading from the CAH to the Clinic. Upon testing of the rolling fire door, it was determined that the manual release device, now in place for the door, required that a ceiling tile be removed to access the release device. This type of action did not instantly release the door in case of emergency. The door could not readily be closed without the use of a ladder and removal of ceiling tiles. No smoke detectors were located within 5 feet on either side of the rolling door to detect the movement of smoke through the opening to automatically release the hold-open mechanism of the fire door and close it. Loss of power would not close the fire door since the release device was not interconnected to the power system. Furthermore, since this type of fire door cannot be used as a means of egress during a fire emergency (it is a non-swinging door), the ramp/corridor in which it is situated would become a dead end requiring a sign at the entry way to the ramp from the CAH signifying that it is NO EXIT per NFPA 101 7.10.8.1. Such a sign was not in place at the time of the survey. No documentation was available for review as to the installation instructions as may concern audible or visual warnings of the door closing, interconnection to the fire alarm system or a means (such as a keyed control) for mechanical opening of the door upon reset of the fire alarm system or smoke detectors.

Based on observations made on April 10, 2013, the facility failed to maintain the fire and smoke resistance rating of interior wall assemblies. These deficiencies affected one of three smoke compartments in the former long term care area and one of two smoke compartments in the basement area which is only accessed by staff.

The findings include:

1. The dining/activity room suite in the A wing/smoke compartment was toured during the survey. This was the only dining/activity room on this wing. Mechanical room #4 is accessed off of this suite and was examined at 11:05 a.m. on April 10, 2013. A flexible 6-inch conduit penetrates the west wall of the mechanical room. The opening around the flexible conduit in the wall assembly was not properly sealed with a flange or other material to maintain the fire and smoke resistance rating of the assembly.

2. The portion of the basement area located under the Administrative offices was toured during the survey. A storage room housing large amounts of combustible materials adjacent to the Maintenance office in this basement area was examined at 2:40 p.m. on April 10, 2013. Directly above the corridor door into this storage room were located conduit and wiring that penetrated the wall assembly. Although sealed at one time, the material used for such purpose had deteriorated with the result that the penetrations were not properly sealed to maintain the fire and smoke resistance rating of the assembly.

Based upon observations made on April 10, 2013, the facility failed to assure that smoke barrier doors closed tightly to resist the passage of smoke and failed to assure that smoke barrier doors within a means of egress swung open without impediment and did not bind on the door frame. These deficiencies affected three of three smoke compartments of the former nursing home building.

The findings include:

1. The set of smoke barrier doors on the A wing/smoke compartment were exercised at 10:49 a.m. on April 10, 2013. These doors were located adjacent to room A-1. The doors were supplied with a gasket material at the meeting edges to restrict the passage of smoke. The gasket material did not completely cover the gap or opening between the doors when exercised.

2. The set of smoke barrier doors on the B wing/smoke compartment were exercised at 3:49 p.m. on April 10, 2013. These doors were located adjacent to room B-1. The south door of this set was observed to be binding on the frame of the door inhibiting it from opening with at least 15 pounds of pressure so as to be used as a means of egress from the B wing/smoke compartment.

Based on observations made on April 10, 2013, the facility failed to assure that a corridor door to a storage room exceeding 50 square feet in size and housing large amounts of combustibles was provided with a self-closure device and failed to prevent the storage of combustible materials in an open crawl space in a building of Type V (111) construction. This deficiency affected one of three smoke compartments in the long term care building and one of two smoke compartments in the basement which is only accessed by staff.

The findings include:

1. An ex-isolation room, located between rooms B-1 and B-3 in the B wing smoke compartment, was examined at 10:17 a.m. on April 10, 2013. This configuration of an ex-isolation room is the only one in this smoke compartment. The room was presently being used as a storage room for large amounts of combustibles and exceeded 50 square feet in size. The entire building was protected by the automatic sprinkler system and the corridor door must have at least a self-closure device. No self-closure device was in place on the corridor door. Note: Communicating doors leading to rooms B-1 and B-3 were not in use and locked in place from this storage room at the time of the survey but would require a self-closure if they were to be used once again as openings.

2. The crawl space under the B wing smoke compartment of the building was examined at 3:21 p.m. on April 10, 2013. The crawl space was sprinklered due to the wood floor/beam construction in that area. Insulation, which has the capability to smolder and produce smoke during a fire, was found to be stored in the open crawl space and not separated by one hour construction from the crawl space.

Based on review of fire alarm service and test reports on April 10, 2013, the facility failed to provide documentation that the fire alarm system was installed and certified in accordance with NFPA 72, 1999 Edition. This deficiency affects all portions of both buildings.

The findings include:

All new fire alarm systems shall be inspected and tested in accordance with the requirements of Chapter 7 per section 7-1.6.1 of NFPA 72, 1999 Edition. After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner's designated representative per section 7-5.1 of NFPA 72. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction (AHJ). Paper or electronic media shall be permitted

The fire alarm service and test reports were reviewed at the facility on April 10, 2013. The fire alarm system serves the entire building. A new Fire Alarm Control Panel (FACP) was installed in 2009 after the last survey of January 20, 2009. The new panel is a Simplex model 4100U addressable panel. Since the facility utilized a majority of the existing smoke detectors to interface with the new panel it shows alarms by zones and also identifies a few smoke detectors by an address. The installation of the FACP required a new certificate of completion that must be kept by the owner for the life of the system and available for examination by the State Agency (AHJ). No certificate of completion was available for review at the time of the survey.

Based on review of the fire alarm and smoke detection service and test records on April 10, 2013, the facility failed to assure that sensitivity tests were conducted in accordance with NFPA 72, 1999 Edition. This deficiency affects all portions of both buildings.

The findings include:

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per section 7-3.2.1 of NFPA 72. 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 Centers for Medicare and Medicaid Services, 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 and smoke detector service and test records were reviewed at the facility on April 10, 2013. The facility has smoke detectors throughout the corridor system of all the smoke compartments and additionally has duct detectors and several individual rooms with smoke detectors. A new Fire Alarm Control Panel (FACP) was installed in 2009 with the retention of many of the existing smoke detectors being interfaced to the new panel. The last documented sensitivity testing recorded by previous surveys occurred on November 9, 2004 and the five year sensitivity tests was due before the end of 2009. With the installation of a new FACP all of the detectors were subject to sensitivity testing upon completion of the new installation and within one year thereafter. No documentation was available that a sensitivity test was conducted on the smoke detectors after the installation of the new FACP or in the subsequent years of 2010, 2011, 2012 or thus far in 2013.

Based on review of the service reports for the automatic fire sprinkler system and on observations made on April 10, 2013, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13, 1999 Edition and NFPA 25, 1998 Edition. These deficiencies affect all portions of both buildings.



The findings include:

Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall per section 2-2.1.1 of NFPA 25. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in improper orientation.

1. The open lounge at the west end of the B wing/smoke compartment was examined at 10:37 a.m. on April 10, 2013. This was the only open area to the corridor in this wing and the opening to the lounge was directly observable from the nurse's station. The sprinkler head in the lounge located near the corridor opening was observed to have a coating of material on it that may be the result of a leakage condition.

2. The six rooms that open onto the west corridor of the Acute Care smoke compartment were examined during the course of the survey. One of these rooms, being a janitor's closet, was observed at 12:50 p.m. on April 10, 2013, to have a sprinkler head coated with foreign material.

3. Four patient rooms on the south corridor of the Acute Care smoke compartment were examined during the course of the survey. One of these rooms, being room 4, was observed at 12:52 p.m. on April 10, 2013, to have a sprinkler head coated with foreign material.

4. The Medical Records suite located on the north corridor of the Administrative/Medical Record/Physical Therapy smoke compartment was examined at 2:12 p.m. on April 10, 2013. A sprinkler head in the main room of the suite was observed to have a coating of material on it that may be the result of a leakage condition.

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per section 3-2.7.2 of NFPA 13 and per UL listing (VNUV guidelines) must be flush with the surface on which they are mounted.

5. The Laboratory located in the Acute Care smoke compartment of the building was examined at 12:41 p.m. on April 10, 2013. This was the only Laboratory located in the building. Two of the ceiling sprinklers in the main Laboratory room were pendent type extending through the suspended tile ceiling assembly. The escutcheons for these two sprinklers did not fully cover the holes for the sprinklers in the ceiling tiles.

Check valves, detector check valves, and backflow preventers, that are installed in the water supply piping system shall be inspected and maintained so that they do not impede the flow of water and fire main pressure in accordance with Chapter 9 of NFPA 25 per section 8-2.8 of NFPA 25. Check valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition per section 9-4.2.1 of NFPA 25. All backflow preventers installed in fire protection system piping shall be tested annually per one of two test methods noted in section 9-6.2.1 of NFPA 25.

6. The sprinkler riser located in the basement of the facility, which provides protection for the entire facility, was examined at 2:32 p.m. on April 10, 2013. The riser was provided with what appeared to be a double check valve assembly. In reviewing the sprinkler report for March 4, 2013, it was noted by the licensed and endorsed contractor that this was a "backflow" device. Dependent upon the actual use of the valve in place, there was no documentation available that it had been tested on either an annual basis for a backflow preventer or on a five year basis for a check valve installation.

Based on observations and review of service records or logs on April 10, 2013, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis. This deficiency affects one of two smoke compartments in the CAH building.

The findings include:

Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal 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. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire 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. It shall also indicate areas not cleaned per 8-3.1.2 of NFPA 96.

The service records or logs were reviewed at the facility on April 10, 2013 and the kitchen hood exhaust system was examined at 11:24 a.m. on April 10, 2013. No documentation was available that the kitchen hood system had been inspected and/or cleaned in the preceding six month period (semiannually) by a properly trained, qualified, and certified company or person(s).

Based on observations made on April 10, 2013, 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 or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies affect all of the smoke compartments for both buildings.

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.

1. Twelve resident rooms were examined in the B wing/smoke compartment during the course of the survey for electrical conformance. A white household type extension cord, without built-in circuit breaker protection, was in use for a TV in room B-6 as observed at 10:30 a.m. on April 10, 2013.

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 K located in the kitchen suite was examined at 11:28 p.m. on April 10, 2013. The listings on the panel board breaker identification card did not correspond exactly to the breakers in use and several breakers did not have a number that related to their listings. An example was breaker numbers 14 and 16 with 16 not being properly identified as to it's use.

3. One of the two electrical panel boards located in the basement room housing the transfer switch for the generator was examined at 3:10 p.m. on April 10, 2013. One of the breakers in this panel board was identified with a red dot signifying that it supplied the power for the Fire Alarm Control Panel (FACP). However, since the new FACP installed in 2009 listed a different panel and breaker other than the one noted, the listings for the panel board in question must be updated to reflect the most current identification.