HospitalInspections.org

Based on observation on August 17, 2011, the facility did not ensure all vertical openings in ceilings or concrete floors were maintained and resistant to the passage of smoke.

Findings include:

At 2:27 p.m., in the Activities Director's office across from resident room #209, four wires were found that penetrated the ceiling and were not sealed with an acceptable fire stop material.

Based on the surveyor's observations of August 17, 2011, the facility failed to ensure that all corridor doors equipped with self closing devices could automatically close to positive latching.

Findings include:

At 1:16 p.m., the corridor door of the Soiled Utility Closet on the 100 Wing did not latch when the door was released by the surveyor from a fully opened position.

Based on surveyor observations made on August 17, 2011, the facility failed to maintain the smoke resistance at all smoke barrier locations.

Findings include:

In accordance with NFPA 101 and Section 8.3.6.1, 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

At 11:28 a.m., the smoke barrier above the ceiling on the 200 Wing was examined. Next to a sprinkler pipe, there was an open hole in the smoke barrier through which two computer wires passed. The opening had not been sealed with an acceptable fire stop material.

Based on the surveyor's observations of August 17, 2011, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. The surveyor inspected the laundry at 10:33 a.m. Above a clothes dryer, a ventilation duct from the dryer penetrates a ceiling tile above the dryer. There is a lack of an acceptable "fire stop" product being used to seal the duct penetration at the level of the ceiling.

2. At approximately 11:54 a.m., the wall between the housekeeping storage closet and the boiler room was examined. There is a two inch pipe penetration which had formerly been sealed. The original sealant has started to crack and has caused the penetration to partially reopen.

Based on observations made on August 17, 2011, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

The findings include:

The building of Type II (111) construction that requires that it be protected throughout by an approved automatic sprinkler system has not been maintained for the building to meet the the standards of NFPA 13, 1999 Edition.

At 11:29 a.m., the east end of the building outside the exit door by the activity room was inspected. There was a lack of sprinkler coverage for a section of the canopy which is approximately five foot by seven foot in size.

Based on observations made on August 17, 2011, it was determined that the facility did not maintain all the components of the sprinkler system in accordance with NFPA 25.

Findings include:

In accordance with NFPA 25, 1998 Edition, Section 2-2.2; "Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

At approximately 2:40 p.m. on 100 Wing in the corridor during examination of the smoke barrier, it was observed that a sprinkler pipe above the ceiling was being used to support wiring.

Based on surveyor observations of August 17, 2011, it was determined there was not an acceptable width for a means of egress from an exit access corridor through a open area to an exit door.

Findings include:

At 2:26 p.m., the surveyor inspected the exit options at the east end of the 200 Wing. It is necessary for a corridor width of 8 feet to be maintained through the open dining/activity area at the end of the 200 Wing corridor. During the last meal served in the dining room, the required width through the activity/dining area was obstructed by a "hemi shaped" dining table used in assisted dining. Placement of dining furniture must be done in a manner to accommodate the need for maintaining the corridor width of the exit access corridor through the open area.

Based on observations made on August 17, 2011, the surveyor determined that not all equipment for the maintenance and testing of the emergency generator was being properly monitored.

Findings include:

In accordance with section 3-4.1.1.15 of NFPA 99 Health Care Facilities 1999 Edition, the following is required, " A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

At 3:12 p.m. when the test switch on the annunciator was turned on, only six of the required nine visual signals gave a testing illumination. The "LO BAT VOLT", "HI BAT VOLT" and "LO ENG. TEMP" did not illuminate.

Based on review of the fire watch policy and interview on August 31, 2011, the facility failed to have a fire watch policy which included contacting the authority having jurisdiction (State Certification Bureau at 406-444-4170) whenever a fire watch was instituted. Additionally, the fire watch policy did not include a fire watch would be started when the automatic sprinkler system was out of service for more than 4 hours in a 24 hour period.

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

Findings include:

A copy of the fire policy was provided to the Certification Bureau on August 31, 2011. The fire watch policy did not addressed contacting the Certification Bureau at 406-444-4170 nor the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period.

An interview with the maintenance staff included a question of whether the current fire watch policy contains that the "State Surveying Agency" is to be called when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The maintenance staff member indicated the policy did not include contacting the State Surveying Agency at 406-444-4170 nor did it include the requirement of notifying the agency when the automatic fire sprinkler system was out of service for more than 4 hours in a 24 hour period.

Based on review of the fire plan on August 31, 2011, the facility failed to have a fire watch policy which included contacting the authority having jurisdiction (State Certification Bureau at 406-444-4170) whenever a fire watch was instituted for the fire alarm system.

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

Findings include:

A copy of the fire watch policy was provided to the Certification Bureau on August 31, 2011. After review, the fire watch policy did not specifically include notification of the State Certification Bureau at 406-444-4170 whenever the fire alarm system was out of service for longer than 4 hours in 24 hour period.

An interview with the maintenance staff included a question of whether the current fire watch policy contains that the "State Surveying Agency" is to be called when the fire alarm system is out of service for more than 4 hours in a 24 hour period. The maintenance staff member indicated that the fire watch policy did not include contacting the State Surveying Agency at 406-444-4170.

Based on observation on August 17, 2011, the facility did not ensure all vertical openings in ceilings or concrete floors were maintained and resistant to the passage of smoke.

Findings include:

At 2:27 p.m., in the Activities Director's office across from resident room #209, four wires were found that penetrated the ceiling and were not sealed with an acceptable fire stop material.

Based on the surveyor's observations of August 17, 2011, the facility failed to ensure that all corridor doors equipped with self closing devices could automatically close to positive latching.

Findings include:

At 1:16 p.m., the corridor door of the Soiled Utility Closet on the 100 Wing did not latch when the door was released by the surveyor from a fully opened position.

Based on surveyor observations made on August 17, 2011, the facility failed to maintain the smoke resistance at all smoke barrier locations.

Findings include:

In accordance with NFPA 101 and Section 8.3.6.1, 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

At 11:28 a.m., the smoke barrier above the ceiling on the 200 Wing was examined. Next to a sprinkler pipe, there was an open hole in the smoke barrier through which two computer wires passed. The opening had not been sealed with an acceptable fire stop material.

Based on the surveyor's observations of August 17, 2011, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. The surveyor inspected the laundry at 10:33 a.m. Above a clothes dryer, a ventilation duct from the dryer penetrates a ceiling tile above the dryer. There is a lack of an acceptable "fire stop" product being used to seal the duct penetration at the level of the ceiling.

2. At approximately 11:54 a.m., the wall between the housekeeping storage closet and the boiler room was examined. There is a two inch pipe penetration which had formerly been sealed. The original sealant has started to crack and has caused the penetration to partially reopen.

Based on observations made on August 17, 2011, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

The findings include:

The building of Type II (111) construction that requires that it be protected throughout by an approved automatic sprinkler system has not been maintained for the building to meet the the standards of NFPA 13, 1999 Edition.

At 11:29 a.m., the east end of the building outside the exit door by the activity room was inspected. There was a lack of sprinkler coverage for a section of the canopy which is approximately five foot by seven foot in size.

Based on observations made on August 17, 2011, it was determined that the facility did not maintain all the components of the sprinkler system in accordance with NFPA 25.

Findings include:

In accordance with NFPA 25, 1998 Edition, Section 2-2.2; "Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

At approximately 2:40 p.m. on 100 Wing in the corridor during examination of the smoke barrier, it was observed that a sprinkler pipe above the ceiling was being used to support wiring.

Based on surveyor observations of August 17, 2011, it was determined there was not an acceptable width for a means of egress from an exit access corridor through a open area to an exit door.

Findings include:

At 2:26 p.m., the surveyor inspected the exit options at the east end of the 200 Wing. It is necessary for a corridor width of 8 feet to be maintained through the open dining/activity area at the end of the 200 Wing corridor. During the last meal served in the dining room, the required width through the activity/dining area was obstructed by a "hemi shaped" dining table used in assisted dining. Placement of dining furniture must be done in a manner to accommodate the need for maintaining the corridor width of the exit access corridor through the open area.

Based on observations made on August 17, 2011, the surveyor determined that not all equipment for the maintenance and testing of the emergency generator was being properly monitored.

Findings include:

In accordance with section 3-4.1.1.15 of NFPA 99 Health Care Facilities 1999 Edition, the following is required, " A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

At 3:12 p.m. when the test switch on the annunciator was turned on, only six of the required nine visual signals gave a testing illumination. The "LO BAT VOLT", "HI BAT VOLT" and "LO ENG. TEMP" did not illuminate.

Based on review of the fire watch policy and interview on August 31, 2011, the facility failed to have a fire watch policy which included contacting the authority having jurisdiction (State Certification Bureau at 406-444-4170) whenever a fire watch was instituted. Additionally, the fire watch policy did not include a fire watch would be started when the automatic sprinkler system was out of service for more than 4 hours in a 24 hour period.

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

Findings include:

A copy of the fire policy was provided to the Certification Bureau on August 31, 2011. The fire watch policy did not addressed contacting the Certification Bureau at 406-444-4170 nor the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period.

An interview with the maintenance staff included a question of whether the current fire watch policy contains that the "State Surveying Agency" is to be called when the automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The maintenance staff member indicated the policy did not include contacting the State Surveying Agency at 406-444-4170 nor did it include the requirement of notifying the agency when the automatic fire sprinkler system was out of service for more than 4 hours in a 24 hour period.

Based on review of the fire plan on August 31, 2011, the facility failed to have a fire watch policy which included contacting the authority having jurisdiction (State Certification Bureau at 406-444-4170) whenever a fire watch was instituted for the fire alarm system.

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

Findings include:

A copy of the fire watch policy was provided to the Certification Bureau on August 31, 2011. After review, the fire watch policy did not specifically include notification of the State Certification Bureau at 406-444-4170 whenever the fire alarm system was out of service for longer than 4 hours in 24 hour period.

An interview with the maintenance staff included a question of whether the current fire watch policy contains that the "State Surveying Agency" is to be called when the fire alarm system is out of service for more than 4 hours in a 24 hour period. The maintenance staff member indicated that the fire watch policy did not include contacting the State Surveying Agency at 406-444-4170.