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Based on observations, the facility failed to ensure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 18.3.2.1.3 and 18.3.2.1.5. These deficiencies affect 1 of 3 smoke compartments.

Findings include:

1. During an observation on 4/8/19 at 1:30 p.m., the gift shop was inspected. The room was measured to be over 100 sq. feet. The room lacked a necessary self-closing device on the door.

Based on observation and record review, the facility failed to document weekly dry pipe gauges and monthly wet system standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.4.4.1.2 and 13.2.7.1, and failed to maintain components of the sprinkler system in accordance with the standards of NFPA 13. These deficiencies affect the entire facility.

Findings include:

1. Review of the facility's quarterly sprinkler inspection reports, reflected the facility lacked supporting documentation to show the facility's automatic sprinkler systems' gauges were inspected and documented weekly for a dry system and montly for a wet system.

During an interview on 4/8/19 at 1:50 p.m., staff member A stated that he did not know that there was a requirement for inspecting and documenting sprinkler gauge readings for wet and dry sprinkler systems. He stated the facility had one wet system and one dry system.

2. Based on observation on 4/8/19 at 12:15 p.m., the facility failed to assure that components of the sprinkler system were in accordance with the standards of NFPA 13, section 6.2.9.6, which states: One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system.

During an interview on 4/8/19 at 12:16 p.m., staff member A stated the sprinkler company used by the facility never gave him wrenches for the sprinkler heads.

Based on record review and interview, the facility failed to implement requirements for fire watches or evacuation whenever the fire sprinkler system was out of service for more than ten hours, in accordance with NFPA 25, 2011 edition. This deficiency affects all residents and staff of the facility.

Findings include:

1. Review of the facility document, "Fire Watch Log Sheet", on 4/8/19 at 9:45 a.m., showed the facility implemented fire watch procedures, which began on 12/5/18 at 10:29 p.m., and ended on 12/6/18 at 1:30 p.m. No documentation was found which indicated that the facility had notified the State Agency that the facility fire sprinkler system was out of service for more than 10 hours in any 24 hour period. Per requirements stated in 15.5.2 of NFPA 25, where the sprinkler system is out of service for more than 10 hours in a 24 hour period, the notification to the authorities having jurisdiction (the State Agency at 406-444-4170) must be made, the building or porion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.

During an interview on 4/8/19 at 1:39 p.m., staff member A stated the facility initiated fire watch procedures, after a sprinkler system pipe burst, which resulted in the facilities sprinkler system being taken out of service. Staff member A stated the sprinkler company was able to come to the facility and repair the pipe the following day. He stated he did not know that he needed to notify the State Agency when the sprinkler system was taken out of service for more than 10 hours within a 24 hour period.

Based on observation, the facility failed to properly mount a fire extinguisher in accordance with NFPA 10, 2010 Edition, Section 6.1.3.8.3. This deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 4/8/19 at 1:09 p.m., the mechanical room was inspected. There was a portable extinguisher sitting on the floor next to a pair of boots and underneath a mounted fire extinguisher.¹ Extinguishers shall be installed no lower than 4 inches from the floor.

¹ NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.3; Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 18.7.1.6. This deficiency can affect all smoke compartments.

Findings include:

1. Review of facility documents regarding fire drills for the last year reflected there was no documentation for completed drills for the morning and overnight shifst of the fourth quarter of 2018.

Based on observation, the facility failed to ensure that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 4/8/19 at 12:01 p.m., the lab was inspected. A power strip was observed placed on top of the counter, with several electrical cords from nearby medical and diagnostic equiptment plugged into it. The power strip observed did not have a UL 1363 rating.

Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1. The deficiency affects the entire building.

Findings include:

1. During an observation on 4/8/19 at 12:23 p.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location outside of the enclosure housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.