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Based on observations and interview it was determined that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19/18.1.2.3, 19/18.1.1.4, 19.1.2.3). Findings include, but are not limited to:

2. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: the 90-minute rated fire door across from the x-ray waiting area was dragging on the floor and not closing. The door was missing an astragal to cover the gap between the meeting edges of the two door leafs.

Based on record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80 for all corridors of the building. This resulted in the potential for the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19/18.2.3.5, (Table 18.3.2.1), 19/18.3.6.3.1 Ex 2, 4.6.12.1, A19.3.6.3.3). Findings include, but are not limited to:

1. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: the facility did not have access to the NFPA 80 1999 edition for inspecting, testing, and maintaining fire and smoke doors in the facility corridors. The facility was not keeping a monthly log of fire and smoke door inspections indicating doors that were found to need correction and the date of completion. The Maintenance Technician acknowledged that the standards were not accessible or used, as required.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19/18.7.1.1). Findings include, but are not limited to:

1. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the facility walk-through there was no viable emergency plan available to staff at the nurse station.

Based on record reviews and interviews it was determined that the facility failed to properly document fire drills. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19/18.7.1.2, A.19/18.7.1.2). Findings include, but are not limited to:

1. On April 16, 2012 at 5:30 p.m., the fire drill forms that were filled out were incomplete and lacking the required information. There was no time listed for simulating the relocation of the smoke compartment. The facility was counting false alarms and actual fires as drills. The specific type of fire simulated was not indicated. The specific location of the fire was not indicated on the forms. The Maintenance Technician acknowledged that the fire drill forms did not contain the required information and stated that they were using the forms they had always used. The facility had no documentation of fire drills being conducted on the 1st and 2nd quarter 2011 second shift and 1st quarter 2012 second shift. There was no documentation of fire drills on 1st and 3rd quarter 2011 first shift.

2. On April 16, 2012 at 5:30 p.m., the facility had no documentation of inservice training for all staff within 30 days of hire and annually.

Surveyor was accompanied by the Maintenance Technician and CEO who acknowledged the existence of these conditions

3. On April 16, 2012 at 6:00 p.m., R.N. #1 was interviewed regarding responding to a fire and the disaster plan at the nurse station. She could not locate a fire alarm pull station on the unit. She stated that the patients would be evacuated to the parking lot to wait for the fire department after being coached by the Maintenance Technician. She stated that she had never heard of "defend in place" though it was in the facility plan. She struggled with the disaster plan due to it being upside down and backwards in the red notebook, she could not locate a fire procedure.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:

3. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the record review process, the facility had no documentation of the required fire alarm testing for the facility in accordance with NFPA 72 other than the annual. They had no documentation of technician competence and did not have access to the adopted standards for testing and maintaining the system. The Maintenance Technician indicated that he was unaware of the requirements for technician competence, access to standards, and the requirements for fire alarm testing.

Based on observations, record review and interviews it was determined that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

2. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the facility record review process, there was no documentation of an annual forward flow test of the fire sprinkler system to ensure adequate water available for the demand of the system as designed. The Maintenance Technician, acknowledged that the forward flow test results were not available for review, and indicated that Alpine Fire Protection did not conduct the test during the 4/29/11 annual inspection.

3. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the record review process, the facility had no documentation of the required sprinkler testing for the facility in accordance with NFPA 25 other than the annual. They had no documentation of technician competence and did not have access to the adopted standards for testing and maintaining the system. The Maintenance Technician indicated that he was unaware of the requirements for technician competence, access to standards, and the requirements for fire sprinkler testing.

Based on record review, observations and interview it was determined that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the record review process the facility had no access to the adopted standards (NFPA 10 1998 edition) for inspecting, testing, and maintaining fire extinguishers.

Based on observations and interview it was determined that the facility failed to maintain the generator room free of storage. This resulted in the potential for unexpected ignition source & excessive fire spread. Findings include, but are not limited to:

1. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the facility walk-thru there was flammable and combustible storage in the Generator room. The facility had cut a hole in the wall between the generator room and the adjacent storage room to provide better air flow, per the CEO.

Based on record review and interviews it was determined that the facility failed to properly maintain the generator in accordance with NFPA 110 for the entire building emergency power supply. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

1. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: during the record review process, the facility had no documentation of the required generator testing for the facility in accordance with NFPA 110 other than the annual. They had no documentation of technician competence and did not have access to the adopted standards for testing and maintaining the system.

3. On June 25, 2012, the facility continued to be out of substantial compliance with the following citation: there were no battery powered emergency lights installed at the generator and transfer switches for troubleshooting the generator.