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Based on observations made during the survey on April 11-13, 2011, the facility failed to assure that all penetrations and openings in the fire walls were sealed with appropriate fire stop material.

Findings include:

In accordance with Sections 18.1.1.4.1 and 18.1.1.4.2 of NFPA 101, (2000 Edition); if the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors.

The fire wall between the existing CAH and the new CAH addition was examined at 4:05 p.m. on April 12, 2011. The wall was examined above the set of 1 and 1/2 hour rated doors between room 106 and the fire sprinkler riser room. There was an open four inch conduit which contained Information Technology (IT) wiring.

Based on observation made on April 11, 2011, the facility failed to ensure that exposed interior finishes of ceilings met the flame spread rating.

Findings include:

In accordance with Section 18.3.3.2 of NFPA 101, (2000 Edition); Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted throughout if Class A or Class B.

The ceiling of the Reflection room (A 128) was observed to be tongue and groove pine and the area was estimated at twelve foot in width by fourteen feet in length. The facility failed to provide documentation from the contractor that it met the flame spread rating for interior surfaces.

Based on observation made on April 11-13, 2011, the facility failed to enclose corridor walls to ensure that they would limit the transfer of smoke.

Findings include:

In accordance with Sections 18.3.6.1, and 18.3.6.2., of NFPA 101, 2000 Edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke.

The Dark room (R 114) was observed which contained a Kodak film developer just outside the room. The shroud making the developer smoke tight to the corridor wall had been removed leaving a large penetration through the corridor wall.

Interview with maintenance staff revealed that the facility was in the process of removing the film developer and would need to repair the wall in order to make the room ready for a newly installed bath.

Based on observations which were made on April 11-13, 2011, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 Edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

Findings include:

The housekeeping equipment room (B 52) was observed at 2:57 p.m. on April 11, 2011. The east wall of this room had a penetration through the corridor wall for a new drain line and was not sealed.

Based on observation on April 11-13, 2011, the facility failed to prevent employees from blocking corridor doors open with wedges.

Findings include:

In accordance with Section 18.2.2.2.6 of NFPA 101; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the
smoke compartment or throughout the entire facility.

In accordance with Section 18.3.6.3.3 of NFPA 101; hold-open devices that release when the door is pushed or pulled shall be permitted.

Corridor doors to rooms A-122 and A-123 were observed to be blocked open with wedges as observed at 10:05 a.m. on April 12, 2011.

Interview with staff who had blocked the doors open revealed that they had done it to more easily observed the admittance area from the back office areas.

Based on observations made on April 11-13, 2011, the facility failed to maintain the smoke resistive construction of doors protecting corridor openings.

The findings include:

In accordance with Section 19.3.6.3.1 of NFPA 101, doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

1. The corridor door to the procedure room (NS-113) was exercised at 4:00 p.m. on April 11, 2011. The corridor door failed to latch properly when exercised on three different tries.

2. The housekeeping closet (N 256) was observed at 8:56 a.m. on April 12, 2011. The corridor door to the closet would not latch when exercised on three tries.

Based on observations made on April 11-13, 2011, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 edition; any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of the LSC. 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.

The Information Technology (IT) room (118 A) was observed at 3:00 p.m. on April 12, 2011. There were two large four inch conduits through the floor which were not sealed which contained IT wire.

Based on observations made on April 11-13, 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.

The Information Technology (IT) (B-49 A) room in the lower level, was observed at 3:30 p.m. on April 11, 2011. There were seven vertical conduits which had not been sealed to the level above.

Based on observations made on April 11-13, 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.

The 2-hour fire wall between the case manager's office and the nursing station on the east side of the fire wall was examined at 4:15 p.m. on April 12, 2011. There was one two inch conduit which was not sealed which contained information technology wires.

Based on observations made on April 11-13, 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.

The Information Technology (IT) room (B-49 A) was observed at 3:31 on April 11, 2011. There was one horizontal penetration of a conduit through the smoke barrier wall which was not sealed.

Based on observations made on April 11-13, 2011, the facility failed to maintain or establish the fire rated protection for hazardous areas.

The findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 18.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

The equipment store room (P 147) was observed at 12:05 p.m. on April 12, 2011. There was a heavy equipment hanger hanging on the corridor door to this room which would not allow the corridor door to latch properly.

Note: the piece of equipment was removed from the door by maintenance staff and the door closed perfectly on the next try.

Based on observations made on April 11-13, 2011, the facility failed to maintain or establish the fire rated protection for hazardous areas.

The findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

1. The shop storeroom known as the plant operations room (B 21) was observed at 1:45 p.m. on April 11, 2011.

a) There was an unsealed penetration for an information technology (IT) wire where it exited the south wall of the room.

b) There was a one half inch conduit not sealed where it exited the south wall of this room.

2. The switch gear room (M 130) was observed at 2:20 p.m. on April 11, 2011.

a) The north wall had four penetrations, three were three quarter inch conduit not sealed, and the remainder was a one and one quarter inch conduit not sealed.

b) The west wall had nine conduits which were open and not sealed.

3. Boiler room #1 was observed at 2:27 p.m. on April 11, 2011. There was an open penetration of the east wall where an oil line enters the boiler room.

4. The Physical Therapy storeroom (B 47) was observed at 3:45 p.m. on April 11, 2011. The storeroom is greater than 50 square feet, contains combustibles, and the storeroom door was not self-closing.

5. The storerooms (NS 103 and NS 115) near Operating Room (OR) suite 2 were observed at 4:20 p.m. on April 11, 2011. They were both larger than 50 square feet, contained combustibles, and lacked a self-closure device for the door.

6. The materials storeroom (M 126) was observed at 4:25 p.m. on April 11, 2011. There were two unsealed penetrations of the west wall, one was a three inch conduit and the remaining was a one inch conduit.

7. The Respiratory Therapy (RT) store room was observed at 4:45 p.m. on April 11, 2011. The room measured six feet by twelve feet, contained combustibles, and lacked a self-closure device for the door.

Based on observation made between April 11-13, 2011, the facility failed to properly identify the breaker supplying power to the Fire Alarm Control Panel in red.

Findings include:

In accordance with 1-5.2.5.2 of NFPA 72 (1999 edition) the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The electrical panel which controls the Fire Alarm Control Panel (FACP) was observed at 10:40 a.m. on April 12, 2011. Breaker #32 which supplies power to the FACP was not identified in red.

Based on observation April 11-13, 2011, the facility failed to install and maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.

Findings include:

Room P 131 was observed at 11:05 a.m. on April 12, 2011. One sprinkler head in this janitorial closet had a clip installed on the head from the original installation.

Based on observations made on April 11-13, 2011, the facility failed to assure that the automatic sprinkler system provided for complete coverage of all portions of the building.

The findings include:

The building is of Type V (111) construction which requires that all portions of the facility be protected by the automatic sprinkler system.

The Plant Operations room (B 22) was observed at 2:00 p.m. on April 11, 2011. The area above the pant operation manager's office was not covered by the installed sprinkler system. The room below was sprinkler protected, but sprinkler protection was not installed to protect the area above the enclosed office. The area not sprinkler protected was approximately eight feet by ten feet.

Based on observations and interview with maintenance staff made on April 11-13, 2011, the facility did not maintain the automatic sprinkler system and/or its components in accordance with NFPA 25.

Findings included:

In accordance with NFPA 25, 1998 Edition, Section 2-2.1.1*Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Additionally, Annex Section A-2-2.1.1 states that the conditions described in this section can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual.

1. The can wash room near the one and one half hour doors at the separation between the nursing home and the Critical Access Hospital was observed at 3:50 p.m. on April 11, 2011. The side-wall sprinkler head in the exit corridor next to the can wash room was not sealed properly.

2. The bath in room (C 134) was observed at 8:36 a.m. on April 12, 2011. The escutcheon ring was missing on the ceiling of the bath.

Based on observations on April 11-13, 2011, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

The 2-A-10 BC type portable fire extinguisher located in the switch gear room (M 130) was observed at 2:27 p.m. on April 11, 2011. The extinguisher had been put in service in 1988, didn't receive a 6-year maintenance in 1994, but received a hydrostatic test in 2000 and failed to receive a 6-year maintenance test in 2006.

Based on observations and staff interview made during the tour of the facility on April 11-13, 2011, the facility failed to provide documentation that the window curtains and valances in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics.

Findings include:

In accordance with 18.7.5.1 and 10.3.1 of the Life Safety Code; 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 tub room (P 144) was examined at 11:40 a.m. on April 12, 2011. There was one sprinkler head located in the center of the room. The room was divided by a solid curtain at about the midpoint of the room. The spray pattern for the sprinkler system was inhibited by the solid curtain in this room.

Based on observations and staff interview made during the tour of the facility on April 11-13, 2011, the facility failed to provide documentation that the window curtains and valances in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics.

Findings include:

In accordance with 19.7.5.1 and 10.3.1 of the Life Safety Code; 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 Doctor's sleep room (C 134) was observed at 8:35 a.m. on April 12, 2011. Someone had covered the window with a piece of plywood and landscaping matting to block out the light when sleeping during the daylight hours. The materials do not meet the requirements in accordance with the standards of NFPA 701 for flame resistant products.

Based on observations made on April 11-13, 2011, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over.

Findings include:

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b 27) of NFPA 99 (1999 Edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The CT Scan room (R 104) was observed at 9:48 a.m. on April 12, 2011. There was one Carbon Dioxide tank not secured in this room. The tank was a larger (K Size) tank.

Based on observations made on April 11-13, 2011, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over.

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b 27) of NFPA 99 (1999 Edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The oxygen storeroom (M 109) was observed at 4:40 p.m. on April 11, 2011. There were three nitrous oxide tanks which were not secured, and one oxygen tank which was not secured. These were the larger K-type cylinders and were not chained to the wall.

Based on observations made on April 11-13, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

1. The electrical panel in the janitorial closet (P 128) was observed at 10:30 a.m. on April 12, 2011. A cart blocked access to the electrical panels labeled: 1CRL3, 1NL3A, 1NC3B and 1NSM2.

In accordance with Article 305 Temporary Wiring of NFPA 70, 1999 Edition, 305-1. Scope; the provisions of this article apply to temporary electrical power and lighting wiring methods that may be of a class less than would be required for a permanent installation. In addition in accordance with Arrticle 305-2. All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

2. Room P 140 was observed at 11:25 a.m. on April 12, 2011. There was a heavy extension cord in use in this office to a paper shredder.

3. The roof area (valley) between the Nursing Home (NH) and the new Critical Access Hospital (CAH) was observed at 2:32 p.m. on April 12, 2011. There were two extension cords in use to supply power to ice melt cords positioned in the rain gutters. Two of the cords were taped together where they joined and they were laying in a valley where water could accumulate and short them out.

Based on observations made on April 11-13, 2011, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 Edition.

The findings include:

Junction boxes shall be provided with covers compatible with the box and suitable for the conditions of use per Article 370.28(c) of NFPA 70.

The materials store room (M 126) was observed at 4:26 p.m. on April 11, 2011. There was a junction box on the ceiling of this room which had the cover missing.

Based on observations made on April 11, 2011, the facility failed to prevent the installation of an Alcohol Based Hand Rub (ABHR) dispenser directly over an ignition source.

The findings include:

In accordance with CMS interpretations (Ref: S&C-05-33) issued on June 9, 2005 Alcohol Based Hand Rub (ABHR) dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Sate Survey Agency (SA) enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

The ABHR dispensers located in rooms B 17 and B 19 of Occupational Therapy (OT) were observed at 2:04 p.m. on April 11, 2011, to be positioned directly over the light switches.

Based on observations made during the survey on April 11-13, 2011, the facility failed to assure that all penetrations and openings in the fire walls were sealed with appropriate fire stop material.

Findings include:

In accordance with Sections 18.1.1.4.1 and 18.1.1.4.2 of NFPA 101, (2000 Edition); if the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors.

The fire wall between the existing CAH and the new CAH addition was examined at 4:05 p.m. on April 12, 2011. The wall was examined above the set of 1 and 1/2 hour rated doors between room 106 and the fire sprinkler riser room. There was an open four inch conduit which contained Information Technology (IT) wiring.

Based on observation made on April 11, 2011, the facility failed to ensure that exposed interior finishes of ceilings met the flame spread rating.

Findings include:

In accordance with Section 18.3.3.2 of NFPA 101, (2000 Edition); Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted throughout if Class A or Class B.

The ceiling of the Reflection room (A 128) was observed to be tongue and groove pine and the area was estimated at twelve foot in width by fourteen feet in length. The facility failed to provide documentation from the contractor that it met the flame spread rating for interior surfaces.

Based on observation made on April 11-13, 2011, the facility failed to enclose corridor walls to ensure that they would limit the transfer of smoke.

Findings include:

In accordance with Sections 18.3.6.1, and 18.3.6.2., of NFPA 101, 2000 Edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke.

The Dark room (R 114) was observed which contained a Kodak film developer just outside the room. The shroud making the developer smoke tight to the corridor wall had been removed leaving a large penetration through the corridor wall.

Interview with maintenance staff revealed that the facility was in the process of removing the film developer and would need to repair the wall in order to make the room ready for a newly installed bath.

Based on observations which were made on April 11-13, 2011, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

In accordance with Sections 19.3.6.1, 19.3.6.2.1, 19.3.6.5 of NFPA 101, 2000 Edition; corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.)

Findings include:

The housekeeping equipment room (B 52) was observed at 2:57 p.m. on April 11, 2011. The east wall of this room had a penetration through the corridor wall for a new drain line and was not sealed.

Based on observation on April 11-13, 2011, the facility failed to prevent employees from blocking corridor doors open with wedges.

Findings include:

In accordance with Section 18.2.2.2.6 of NFPA 101; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the
smoke compartment or throughout the entire facility.

In accordance with Section 18.3.6.3.3 of NFPA 101; hold-open devices that release when the door is pushed or pulled shall be permitted.

Corridor doors to rooms A-122 and A-123 were observed to be blocked open with wedges as observed at 10:05 a.m. on April 12, 2011.

Interview with staff who had blocked the doors open revealed that they had done it to more easily observed the admittance area from the back office areas.

Based on observations made on April 11-13, 2011, the facility failed to maintain the smoke resistive construction of doors protecting corridor openings.

The findings include:

In accordance with Section 19.3.6.3.1 of NFPA 101, doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

1. The corridor door to the procedure room (NS-113) was exercised at 4:00 p.m. on April 11, 2011. The corridor door failed to latch properly when exercised on three different tries.

2. The housekeeping closet (N 256) was observed at 8:56 a.m. on April 12, 2011. The corridor door to the closet would not latch when exercised on three tries.

Based on observations made on April 11-13, 2011, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 edition; any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of the LSC. 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.

The Information Technology (IT) room (118 A) was observed at 3:00 p.m. on April 12, 2011. There were two large four inch conduits through the floor which were not sealed which contained IT wire.

Based on observations made on April 11-13, 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.

The Information Technology (IT) (B-49 A) room in the lower level, was observed at 3:30 p.m. on April 11, 2011. There were seven vertical conduits which had not been sealed to the level above.

Based on observations made on April 11-13, 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.

The 2-hour fire wall between the case manager's office and the nursing station on the east side of the fire wall was examined at 4:15 p.m. on April 12, 2011. There was one two inch conduit which was not sealed which contained information technology wires.

Based on observations made on April 11-13, 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.

The Information Technology (IT) room (B-49 A) was observed at 3:31 on April 11, 2011. There was one horizontal penetration of a conduit through the smoke barrier wall which was not sealed.

Based on observations made on April 11-13, 2011, the facility failed to maintain or establish the fire rated protection for hazardous areas.

The findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 18.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

The equipment store room (P 147) was observed at 12:05 p.m. on April 12, 2011. There was a heavy equipment hanger hanging on the corridor door to this room which would not allow the corridor door to latch properly.

Note: the piece of equipment was removed from the door by maintenance staff and the door closed perfectly on the next try.

Based on observations made on April 11-13, 2011, the facility failed to maintain or establish the fire rated protection for hazardous areas.

The findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with one hour rated wall and ceiling assemblies.

1. The shop storeroom known as the plant operations room (B 21) was observed at 1:45 p.m. on April 11, 2011.

a) There was an unsealed penetration for an information technology (IT) wire where it exited the south wall of the room.

b) There was a one half inch conduit not sealed where it exited the south wall of this room.

2. The switch gear room (M 130) was observed at 2:20 p.m. on April 11, 2011.

a) The north wall had four penetrations, three were three quarter inch conduit not sealed, and the remainder was a one and one quarter inch conduit not sealed.

b) The west wall had nine conduits which were open and not sealed.

3. Boiler room #1 was observed at 2:27 p.m. on April 11, 2011. There was an open penetration of the east wall where an oil line enters the boiler room.

4. The Physical Therapy storeroom (B 47) was observed at 3:45 p.m. on April 11, 2011. The storeroom is greater than 50 square feet, contains combustibles, and the storeroom door was not self-closing.

5. The storerooms (NS 103 and NS 115) near Operating Room (OR) suite 2 were observed at 4:20 p.m. on April 11, 2011. They were both larger than 50 square feet, contained combustibles, and lacked a self-closure device for the door.

6. The materials storeroom (M 126) was observed at 4:25 p.m. on April 11, 2011. There were two unsealed penetrations of the west wall, one was a three inch conduit and the remaining was a one inch conduit.

7. The Respiratory Therapy (RT) store room was observed at 4:45 p.m. on April 11, 2011. The room measured six feet by twelve feet, contained combustibles, and lacked a self-closure device for the door.

Based on review of battery powered emergency light fixture testing logs and interview with maintenance staff on April 11-13, 2011, the facility did not ensure that the required 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.

The battery powered emergency light fixture test logs were reviewed at 11:30 a.m. on April 11, 2011.

An interview with staff member A at this same time revealed that testing of the battery pack emergency lighting for 2010 was not done. When questioned about the annual testing, staff member A indicated the facility did not know about the requirement for annual testing of emergency battery pack lighting fixtures.

Based on observation made between April 11-13, 2011, the facility failed to properly identify the breaker supplying power to the Fire Alarm Control Panel in red.

Findings include:

In accordance with 1-5.2.5.2 of NFPA 72 (1999 edition) the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The electrical panel which controls the Fire Alarm Control Panel (FACP) was observed at 10:40 a.m. on April 12, 2011. Breaker #32 which supplies power to the FACP was not identified in red.

Based on observation April 11-13, 2011, the facility failed to install and maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.

Findings include:

Room P 131 was observed at 11:05 a.m. on April 12, 2011. One sprinkler head in this janitorial closet had a clip installed on the head from the original installation.

Based on observations made on April 11-13, 2011, the facility failed to assure that the automatic sprinkler system provided for complete coverage of all portions of the building.

The findings include:

The building is of Type V (111) construction which requires that all portions of the facility be protected by the automatic sprinkler system.

The Plant Operations room (B 22) was observed at 2:00 p.m. on April 11, 2011. The area above the pant operation manager's office was not covered by the installed sprinkler system. The room below was sprinkler protected, but sprinkler protection was not installed to protect the area above the enclosed office. The area not sprinkler protected was approximately eight feet by ten feet.

Based on observations and interview with maintenance staff made on April 11-13, 2011, the facility did not maintain the automatic sprinkler system and/or its components in accordance with NFPA 25.

Findings included:

In accordance with NFPA 25, 1998 Edition, Section 2-2.1.1*Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Additionally, Annex Section A-2-2.1.1 states that the conditions described in this section can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual.

1. The can wash room near the one and one half hour doors at the separation between the nursing home and the Critical Access Hospital was observed at 3:50 p.m. on April 11, 2011. The side-wall sprinkler head in the exit corridor next to the can wash room was not sealed properly.

2. The bath in room (C 134) was observed at 8:36 a.m. on April 12, 2011. The escutcheon ring was missing on the ceiling of the bath.

Based on observations on April 11-13, 2011, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

The 2-A-10 BC type portable fire extinguisher located in the switch gear room (M 130) was observed at 2:27 p.m. on April 11, 2011. The extinguisher had been put in service in 1988, didn't receive a 6-year maintenance in 1994, but received a hydrostatic test in 2000 and failed to receive a 6-year maintenance test in 2006.

Based on observations and staff interview made during the tour of the facility on April 11-13, 2011, the facility failed to provide documentation that the window curtains and valances in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics.

Findings include:

In accordance with 18.7.5.1 and 10.3.1 of the Life Safety Code; 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 tub room (P 144) was examined at 11:40 a.m. on April 12, 2011. There was one sprinkler head located in the center of the room. The room was divided by a solid curtain at about the midpoint of the room. The spray pattern for the sprinkler system was inhibited by the solid curtain in this room.

Based on observations and staff interview made during the tour of the facility on April 11-13, 2011, the facility failed to provide documentation that the window curtains and valances in use were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics.

Findings include:

In accordance with 19.7.5.1 and 10.3.1 of the Life Safety Code; 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 Doctor's sleep room (C 134) was observed at 8:35 a.m. on April 12, 2011. Someone had covered the window with a piece of plywood and landscaping matting to block out the light when sleeping during the daylight hours. The materials do not meet the requirements in accordance with the standards of NFPA 701 for flame resistant products.

Based on observations made on April 11-13, 2011, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over.

Findings include:

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b 27) of NFPA 99 (1999 Edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The CT Scan room (R 104) was observed at 9:48 a.m. on April 12, 2011. There was one Carbon Dioxide tank not secured in this room. The tank was a larger (K Size) tank.

Based on observations made on April 11-13, 2011, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over.

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b 27) of NFPA 99 (1999 Edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The oxygen storeroom (M 109) was observed at 4:40 p.m. on April 11, 2011. There were three nitrous oxide tanks which were not secured, and one oxygen tank which was not secured. These were the larger K-type cylinders and were not chained to the wall.

Based on observations made on April 11-13, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings included:

According to NFPA 70 Article 110-26, sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

1. The electrical panel in the janitorial closet (P 128) was observed at 10:30 a.m. on April 12, 2011. A cart blocked access to the electrical panels labeled: 1CRL3, 1NL3A, 1NC3B and 1NSM2.

In accordance with Article 305 Temporary Wiring of NFPA 70, 1999 Edition, 305-1. Scope; the provisions of this article apply to temporary electrical power and lighting wiring methods that may be of a class less than would be required for a permanent installation. In addition in accordance with Arrticle 305-2. All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

2. Room P 140 was observed at 11:25 a.m. on April 12, 2011. There was a heavy extension cord in use in this office to a paper shredder.

3. The roof area (valley) between the Nursing Home (NH) and the new Critical Access Hospital (CAH) was observed at 2:32 p.m. on April 12, 2011. There were two extension cords in use to supply power to ice melt cords positioned in the rain gutters. Two of the cords were taped together where they joined and they were laying in a valley where water could accumulate and short them out.

Based on observations made on April 11-13, 2011, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, 1999 Edition.

The findings include:

Junction boxes shall be provided with covers compatible with the box and suitable for the conditions of use per Article 370.28(c) of NFPA 70.

The materials store room (M 126) was observed at 4:26 p.m. on April 11, 2011. There was a junction box on the ceiling of this room which had the cover missing.