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Based on observations made on January 30, 2012, the facility failed to maintain the two-hour fire resistance rating of a fire barrier wall.

The findings include:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected per section 8.2.3.2.4.2 of the Life Safety Code as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

The fire barrier wall above the Laboratory/X-Ray Director's office ceiling area was examined at 2:37 p.m. on January 30, 2012. A penetration for a flexible conduit in the barrier wall was not sealed with a material or device that was capable of maintaining the fire resistance of the fire barrier.

Based on observations made on January 30, 2012, the facility failed to assure that a set of corridor doors had positive latching hardware and failed to assure that there was no impediment to closing a corridor door.

The findings include:

1. The set of same swing doors into the emergency room from the ambulance canopy exit corridor were examined at 1:10 p.m. on January 30, 2012. The doors did not have positive latching hardware on them.

In accordance with 18.3.6.3.3 of NFPA 101, hold-open devices that release when the door is pushed or pulled shall be permitted. Guidance from the Annex A.18.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

2. The corridor door to the tub room on the north patient wing was examined at 1:22 p.m. on January 30, 2012. The room was not occupied or in use at the time of the observation and the corridor door was being held open by a wood chock.

Based on observations made on January 30, 2012, the facility failed to provide for acceptable means of holding open a rated fire door in a two-hour fire barrier.

The findings include:

Doors in fire barriers shall normally be kept closed and and shall be protected by approved self-closing fire doors per sections 18.1.1.4.2 and 18.1.1.4.3 of the Life Safety Code. Exception: Doors shall be permitted to be held open if they meet the requirements of 18.2.2.2.6 of the Life Safety Code. Any door in a horizontal exit (fire barrier) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2 of the Life Safety Code. 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.

1. The Clinic was separated from the Critical Access Hospital (CAH) by a two-hour fire barrier. The communicating opening, being a one and one-half hour fire rated door, between the Clinic and the exit corridor of the CAH (which serves the Emergency Room and X-Ray) was examined at 2:04 p.m. on January 30, 2012. The fire door was held open by a wood chock, which does not meet the requirement of 18.2.2.26 for an automatic release device.

2. The Clinic was separated from the Critical Access Hospital (CAH) by a two-hour fire barrier. The communicating opening, being a one and one-half hour fire rated door, between the Laboratory and the reception room for the Laboratory/X-Ray Director's office was examined at 2:07 p.m. on January 30, 2012. The fire door was held open by a plastic chock, which does not meet the requirement of 18.2.2.26 for an automatic release device.

Based on review of the generator test logs and other maintenance logs on January 30, 2012, the facility failed to assure that battery-powered emergency lights were tested on a monthly and annual basis.

The findings include:

The location of the emergency generator and components serving a Type I Essential Electrical System shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and section 5-3.1 of NFPA 110, 1999 Edition. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half 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.

During the course of the survey on January 30, 2012, battery-powered emergency lights were observed to be located in the building housing the emergency generator and in the room housing the three transfer switches. These emergency lights consisted of an overhead fluorescent lamp fixture with a built-in battery pack and red indicator light as to charging capability. No documentation was available that these battery-powered lights had been tested on a monthly or an annual basis.

Based on review of the fire drill reports on January 30, 2012, the facility failed to assure that fire drills were conducted on each shift at least quarterly.

The findings include:

1. The fire drill reports were reviewed at the facility on January 30, 2012. The facility has two 12-hour shifts, being from 7 p.m. to 7 a.m. and from 7 a.m. to 7 p.m. during the week. In reviewing the fire drill reports, the following were noted:
a.) There was no documentation that fire drills had been conducted on the evening shift (7 p.m. to 7 a.m.) during any of the four quarters of 2011.
b.) There was no documentation that fire drills had been conducted on the day shift (7 a.m. to 7 p.m.) during the first and third quarters of 2011.
c.) The fire drills conducted on December 13, 2011 and January 12, 2012 were presumed to be on the day shift, but lacked the notation of the time of the drill to confirm this assumption.

Based on review of the fire alarm service reports and observations made on January 30, 2012, the facility failed to assure that the strobe component (visible appliance) of a notification device interconnected to the fire alarm system functioned correctly.

The findings include:

Visible notification appliances shall be located and be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation per section 4-4.3.1 of NFPA 72, 1999 Edition. The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity) per section 4-4.2.2 of NFPA 72.

The fire alarm service reports were reviewed at the facility on January 30, 2012. The report dated January 12, 2012, noted that the combination alarm/strobe notification device located near the exterior exit door on the north wing (the wing leading to the Long Term Care facility) did not function properly. The strobe unit of the device failed to activate. A fire drill with alarm activation was held at 2:47 p.m. on January 30, 2012 and the strobe device did not function during the drill.

Based on observations and review of construction plans made on January 30, 2012, the facility failed to provide for sprinkler coverage for a canopy exceeding 4 feet in width.

The findings include:

Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width per section 5-13.8.1 of NFPA 13, 1999 Edition. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

According to the facility's limited blueprints available at the time of the survey and the State approval inspection done on May 12, 2004, the facility was classified as Type V (111) construction. Type V (111) buildings require a complete automatic sprinkler system to be installed providing coverage to all areas of the building per section 18.3.5.1 of the Life Safety Code.

The outside canopy on the exterior exit directly to the east of the nurse's station was examined at 1:00 p.m. on January 30, 2012. Although the canopy has a metal fascia it could not be verified that it was of completely non-combustible or limited combustible design to meet the exceptions granted in 5-13.8.1 of NFPA 13. The canopy was 6 feet 2 inches in width. Based on the fact that the construction type for the building is V (111), this canopy requires sprinkler protection.

Based on review of the sprinkler service and inspection reports on January 30, 2012, the facility failed to assure that the backflow preventer device on the fire sprinkler riser system had been tested on an annual basis in accordance with NFPA 25, 1998 Edition.

The findings include:

All backflow preventers installed in fire protection system piping shall be tested annually per section 9-6.2.1 of NFPA 25 in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

The sprinkler service and inspection reports were reviewed on January 30, 2012 at the facility. The four quarterly reports reviewed for the year 2011 noted that a 4 inch backflow device was in place and under item 5(g) of the reports it stated "Did alarm valves, waterflow alarm indicators and retards test satisfactorily". On all four reports this item was checked "Yes'. However, there was no specific verification that an annual test of the backflow preventer device as required by NFPA 25 had been performed.

Based on observations made on January 30, 2012, the facility failed to assure that cubicle curtains were flame resistant or had been treated with a flame retardant product made for fabric application.

The findings include:

An alcove between the exit corridor and the X-Ray room had a blue colored cubicle curtain hanging in the entry way to the alcove for privacy purposes as observed at 1:55 p.m. on January 30, 2012. There was no tag or label on the cubicle curtain ascertaining that it was flame resistant, nor was there any documentation that it had been treated with a flame retardant product.

Based on observations made on January 30, 2012, the facility failed to assure that oxygen cylinders were protected against being knocked down or falling over.

The findings include:

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 main oxygen storage room was examined at 1:08 p.m. on January 30, 2012. Seven "K" cylinders of oxygen were observed to be freestanding and not secured against falling over or being knocked. Note: The cylinders were secured with a chain after the observation was made and confirmed by the surveyor while on-site.

Based on observations and review of maintenance records and reports on January 30, 2012, the facility failed to assure that combination fire/smoke dampers closed upon activation of the fire alarm system and failed to assure that the fusible links within the combination fire/smoke dampers were checked on a six year basis.

The findings include:

Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more per section 3-3.1.1 of NFPA 90A, 1999 Edition. The installation of combination fire and smoke damper shall meet the fire damper requirement.

1. A fire drill was conducted at 2:47 p.m. on January 30, 2012. Four combination fire/smoke dampers were observed for performance during the alarm activation in the ceiling area above the Home Health office in the two-hour barrier between the Clinic and the Critical Access Hospital. One of the four, that being the one next to the south wall of the room, did not open upon the reset of the fire alarm system.

All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct per section 3-4.5.1 of NFPA 90A. At least every 4 years, fusible links (where applicable) shall be removed from all fire or fire/smoke combination dampers and the dampers shall be operated to verify that they fully close and moving parts shall be lubricated as necessary per section 3-4.7 of NFPA 90A. Fusible links shall be replaced if they are found to be broken or damaged. The Centers for Medicaid and Medicare Services (CMS) allows hospitals to perform testing intervals of 6 years instead of 4 years per Survey & Certification Letter (S&C) 10-04-LSC issued October 30, 2009.

2. Maintenance records and reports were reviewed at the facility on January 30, 2012. No documentation that the fusible links in the combination fire/smoke dampers had been tested or inspected since the initial installation in 2004 was available. The fusible links were due for a six year test in 2010.

Based on observations made on January 30, 2012, the facility failed to post the proper precautionary signs at either rooms where oxygen was being administered or at all the main entrances to the facility.

The findings include:

Precautionary signs, readable from a distance of 5 feet shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area per section 8-6.4.2 of NFPA 99, 1999 Edition. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. Exception: In health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no-smoking language are not required. The nonsmoking policies shall be strictly enforced.

The patient rooms all had piped-in oxygen to them as verified during the tour of the building on January 30, 2012. The rooms did not have individual signs concerning the prohibition of smoking when oxygen was in use. Furthermore, during the course of the survey on January 30, 2012, it was observed that at two of the entrances used by staff or the public there were no signs posted as to "No Smoking" in the Critical Access Hospital building. The two entryways were the horizontal exit to and from the Long Term Care building and the exterior entry/exit to the parking lot on the corridor to the Long Term Care building.

Based on review of the emergency generator test logs on January 30, 2012, the facility failed to assure that the generator assumed the load conditions within 10 seconds and failed to assure that the generator was tested under load conditions for at least 30 minutes each month. Furthermore, the facility failed to assure that the generator (serving a Type I Essential Electrical System) met the requirements for an annual load bank test if certain conditions are not met on each monthly test and failed to document that weekly inspections of the generator were occurring.

The findings include:

The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1 for a Type I Essential Electrical System (EES) per section 3-4.4.1.1 of NFPA 99, 1999 Edition.

1. The logs for the emergency generator were reviewed at the facility on January 30, 2012. The log for October 5, 2011, notes that the generator "Took 45-60 seconds to transfer (waiting to sync)". The log for the next monthly test on November 17, 2011, notes that "Phase Sync took a while to connect 30-45 sec." Based on these notations it appears that the emergency generator did not assume the load conditions within 10 seconds.

Generator sets in Type I EES service shall be exercised at least once monthly, for a minimum of 30 minutes per section 6-4.2 of NFPA 110, 1999 Edition, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the nameplate rating or (b) loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Diesel-powered generator installations that do not meet the requirements of 6-4.2 of NFPA 110 shall be exercised monthly with the available load. The date and time of day for required testing shall be decided by the owner, based on facility operations.

2. The logs for the emergency generator were reviewed at the facility on January 30, 2012. The load tests were documented on a log sheet. Several tests denoted that the generator was run under load conditions for at least 30 minutes or in some cases an hour during a particular month. Other load test logs only contained the starting times of the load tests and did not confirm that the tests actually ran for at least 30 minutes. Those monthly tests that included only a starting time were performed on:
a.) May 9, 2011 starting at 10:40 a.m.
b.) September 10, 2011 starting at 0705.
c.) October 5, 2011 starting at 0515.
d.) November 17, 2011 starting at 0700.
e.) November 18, 2011 starting at 6:10 a.m.
f.) December 15, 2011 starting at 5:10 a.m.
g.) January 26, 2012 starting at 5:05 a.m.

Diesel-powered emergency generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available load and then subject to a load bank test annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours pet section 6-4.2.2 of NFPA 110.

3. The maintenance logs for the emergency generator were reviewed at the facility on January 30, 2012 and monthly tests were being conducted but no indication was noted at to meeting either method described above in 6-4.2 of NFPA 110. In addition, the initial installation test for the emergency generator dated March 17, 2004 was reviewed that included a load test but did not document if the requirements of 6-4.2 of NFPA 110 were being met. In lieu of such confirmation an annual load test meeting the parameters of 6-4.2.2 of NFPA 110 would be required of the generator and such documentation was not available for 2011.

Emergency generators serving a Type I EES, including all appurtenant components, shall be inspected weekly per section 6-4.1 of NFPA 110.

4. The logs for the emergency generator were reviewed at the facility on January 30, 2012. There was no documentation available that the emergency generator was being inspected on a weekly basis.

Based on observations made on January 30, 2012, the facility failed to maintain the two-hour fire resistance rating of a fire barrier wall.

The findings include:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected per section 8.2.3.2.4.2 of the Life Safety Code as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

The fire barrier wall above the Laboratory/X-Ray Director's office ceiling area was examined at 2:37 p.m. on January 30, 2012. A penetration for a flexible conduit in the barrier wall was not sealed with a material or device that was capable of maintaining the fire resistance of the fire barrier.

Based on observations made on January 30, 2012, the facility failed to assure that a set of corridor doors had positive latching hardware and failed to assure that there was no impediment to closing a corridor door.

The findings include:

1. The set of same swing doors into the emergency room from the ambulance canopy exit corridor were examined at 1:10 p.m. on January 30, 2012. The doors did not have positive latching hardware on them.

In accordance with 18.3.6.3.3 of NFPA 101, hold-open devices that release when the door is pushed or pulled shall be permitted. Guidance from the Annex A.18.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

2. The corridor door to the tub room on the north patient wing was examined at 1:22 p.m. on January 30, 2012. The room was not occupied or in use at the time of the observation and the corridor door was being held open by a wood chock.

Based on observations made on January 30, 2012, the facility failed to provide for acceptable means of holding open a rated fire door in a two-hour fire barrier.

The findings include:

Doors in fire barriers shall normally be kept closed and and shall be protected by approved self-closing fire doors per sections 18.1.1.4.2 and 18.1.1.4.3 of the Life Safety Code. Exception: Doors shall be permitted to be held open if they meet the requirements of 18.2.2.2.6 of the Life Safety Code. Any door in a horizontal exit (fire barrier) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2 of the Life Safety Code. 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.

1. The Clinic was separated from the Critical Access Hospital (CAH) by a two-hour fire barrier. The communicating opening, being a one and one-half hour fire rated door, between the Clinic and the exit corridor of the CAH (which serves the Emergency Room and X-Ray) was examined at 2:04 p.m. on January 30, 2012. The fire door was held open by a wood chock, which does not meet the requirement of 18.2.2.26 for an automatic release device.

2. The Clinic was separated from the Critical Access Hospital (CAH) by a two-hour fire barrier. The communicating opening, being a one and one-half hour fire rated door, between the Laboratory and the reception room for the Laboratory/X-Ray Director's office was examined at 2:07 p.m. on January 30, 2012. The fire door was held open by a plastic chock, which does not meet the requirement of 18.2.2.26 for an automatic release device.

Based on review of the generator test logs and other maintenance logs on January 30, 2012, the facility failed to assure that battery-powered emergency lights were tested on a monthly and annual basis.

The findings include:

The location of the emergency generator and components serving a Type I Essential Electrical System shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and section 5-3.1 of NFPA 110, 1999 Edition. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half 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.

During the course of the survey on January 30, 2012, battery-powered emergency lights were observed to be located in the building housing the emergency generator and in the room housing the three transfer switches. These emergency lights consisted of an overhead fluorescent lamp fixture with a built-in battery pack and red indicator light as to charging capability. No documentation was available that these battery-powered lights had been tested on a monthly or an annual basis.

Based on review of the fire drill reports on January 30, 2012, the facility failed to assure that fire drills were conducted on each shift at least quarterly.

The findings include:

1. The fire drill reports were reviewed at the facility on January 30, 2012. The facility has two 12-hour shifts, being from 7 p.m. to 7 a.m. and from 7 a.m. to 7 p.m. during the week. In reviewing the fire drill reports, the following were noted:
a.) There was no documentation that fire drills had been conducted on the evening shift (7 p.m. to 7 a.m.) during any of the four quarters of 2011.
b.) There was no documentation that fire drills had been conducted on the day shift (7 a.m. to 7 p.m.) during the first and third quarters of 2011.
c.) The fire drills conducted on December 13, 2011 and January 12, 2012 were presumed to be on the day shift, but lacked the notation of the time of the drill to confirm this assumption.

Based on review of the fire alarm service reports and observations made on January 30, 2012, the facility failed to assure that the strobe component (visible appliance) of a notification device interconnected to the fire alarm system functioned correctly.

The findings include:

Visible notification appliances shall be located and be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation per section 4-4.3.1 of NFPA 72, 1999 Edition. The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity) per section 4-4.2.2 of NFPA 72.

The fire alarm service reports were reviewed at the facility on January 30, 2012. The report dated January 12, 2012, noted that the combination alarm/strobe notification device located near the exterior exit door on the north wing (the wing leading to the Long Term Care facility) did not function properly. The strobe unit of the device failed to activate. A fire drill with alarm activation was held at 2:47 p.m. on January 30, 2012 and the strobe device did not function during the drill.

Based on observations and review of construction plans made on January 30, 2012, the facility failed to provide for sprinkler coverage for a canopy exceeding 4 feet in width.

The findings include:

Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width per section 5-13.8.1 of NFPA 13, 1999 Edition. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

According to the facility's limited blueprints available at the time of the survey and the State approval inspection done on May 12, 2004, the facility was classified as Type V (111) construction. Type V (111) buildings require a complete automatic sprinkler system to be installed providing coverage to all areas of the building per section 18.3.5.1 of the Life Safety Code.

The outside canopy on the exterior exit directly to the east of the nurse's station was examined at 1:00 p.m. on January 30, 2012. Although the canopy has a metal fascia it could not be verified that it was of completely non-combustible or limited combustible design to meet the exceptions granted in 5-13.8.1 of NFPA 13. The canopy was 6 feet 2 inches in width. Based on the fact that the construction type for the building is V (111), this canopy requires sprinkler protection.

Based on review of the sprinkler service and inspection reports on January 30, 2012, the facility failed to assure that the backflow preventer device on the fire sprinkler riser system had been tested on an annual basis in accordance with NFPA 25, 1998 Edition.

The findings include:

All backflow preventers installed in fire protection system piping shall be tested annually per section 9-6.2.1 of NFPA 25 in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

The sprinkler service and inspection reports were reviewed on January 30, 2012 at the facility. The four quarterly reports reviewed for the year 2011 noted that a 4 inch backflow device was in place and under item 5(g) of the reports it stated "Did alarm valves, waterflow alarm indicators and retards test satisfactorily". On all four reports this item was checked "Yes'. However, there was no specific verification that an annual test of the backflow preventer device as required by NFPA 25 had been performed.

Based on observations made on January 30, 2012, the facility failed to assure that cubicle curtains were flame resistant or had been treated with a flame retardant product made for fabric application.

The findings include:

An alcove between the exit corridor and the X-Ray room had a blue colored cubicle curtain hanging in the entry way to the alcove for privacy purposes as observed at 1:55 p.m. on January 30, 2012. There was no tag or label on the cubicle curtain ascertaining that it was flame resistant, nor was there any documentation that it had been treated with a flame retardant product.

Based on observations made on January 30, 2012, the facility failed to assure that oxygen cylinders were protected against being knocked down or falling over.

The findings include:

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 main oxygen storage room was examined at 1:08 p.m. on January 30, 2012. Seven "K" cylinders of oxygen were observed to be freestanding and not secured against falling over or being knocked. Note: The cylinders were secured with a chain after the observation was made and confirmed by the surveyor while on-site.

Based on observations and review of maintenance records and reports on January 30, 2012, the facility failed to assure that combination fire/smoke dampers closed upon activation of the fire alarm system and failed to assure that the fusible links within the combination fire/smoke dampers were checked on a six year basis.

The findings include:

Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more per section 3-3.1.1 of NFPA 90A, 1999 Edition. The installation of combination fire and smoke damper shall meet the fire damper requirement.

1. A fire drill was conducted at 2:47 p.m. on January 30, 2012. Four combination fire/smoke dampers were observed for performance during the alarm activation in the ceiling area above the Home Health office in the two-hour barrier between the Clinic and the Critical Access Hospital. One of the four, that being the one next to the south wall of the room, did not open upon the reset of the fire alarm system.

All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct per section 3-4.5.1 of NFPA 90A. At least every 4 years, fusible links (where applicable) shall be removed from all fire or fire/smoke combination dampers and the dampers shall be operated to verify that they fully close and moving parts shall be lubricated as necessary per section 3-4.7 of NFPA 90A. Fusible links shall be replaced if they are found to be broken or damaged. The Centers for Medicaid and Medicare Services (CMS) allows hospitals to perform testing intervals of 6 years instead of 4 years per Survey & Certification Letter (S&C) 10-04-LSC issued October 30, 2009.

2. Maintenance records and reports were reviewed at the facility on January 30, 2012. No documentation that the fusible links in the combination fire/smoke dampers had been tested or inspected since the initial installation in 2004 was available. The fusible links were due for a six year test in 2010.

Based on observations made on January 30, 2012, the facility failed to post the proper precautionary signs at either rooms where oxygen was being administered or at all the main entrances to the facility.

The findings include:

Precautionary signs, readable from a distance of 5 feet shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area per section 8-6.4.2 of NFPA 99, 1999 Edition. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. Exception: In health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no-smoking language are not required. The nonsmoking policies shall be strictly enforced.

The patient rooms all had piped-in oxygen to them as verified during the tour of the building on January 30, 2012. The rooms did not have individual signs concerning the prohibition of smoking when oxygen was in use. Furthermore, during the course of the survey on January 30, 2012, it was observed that at two of the entrances used by staff or the public there were no signs posted as to "No Smoking" in the Critical Access Hospital building. The two entryways were the horizontal exit to and from the Long Term Care building and the exterior entry/exit to the parking lot on the corridor to the Long Term Care building.

Based on review of the emergency generator test logs on January 30, 2012, the facility failed to assure that the generator assumed the load conditions within 10 seconds and failed to assure that the generator was tested under load conditions for at least 30 minutes each month. Furthermore, the facility failed to assure that the generator (serving a Type I Essential Electrical System) met the requirements for an annual load bank test if certain conditions are not met on each monthly test and failed to document that weekly inspections of the generator were occurring.

The findings include:

The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1 for a Type I Essential Electrical System (EES) per section 3-4.4.1.1 of NFPA 99, 1999 Edition.

1. The logs for the emergency generator were reviewed at the facility on January 30, 2012. The log for October 5, 2011, notes that the generator "Took 45-60 seconds to transfer (waiting to sync)". The log for the next monthly test on November 17, 2011, notes that "Phase Sync took a while to connect 30-45 sec." Based on these notations it appears that the emergency generator did not assume the load conditions within 10 seconds.

Generator sets in Type I EES service shall be exercised at least once monthly, for a minimum of 30 minutes per section 6-4.2 of NFPA 110, 1999 Edition, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the nameplate rating or (b) loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Diesel-powered generator installations that do not meet the requirements of 6-4.2 of NFPA 110 shall be exercised monthly with the available load. The date and time of day for required testing shall be decided by the owner, based on facility operations.

2. The logs for the emergency generator were reviewed at the facility on January 30, 2012. The load tests were documented on a log sheet. Several tests denoted that the generator was run under load conditions for at least 30 minutes or in some cases an hour during a particular month. Other load test logs only contained the starting times of the load tests and did not confirm that the tests actually ran for at least 30 minutes. Those monthly tests that included only a starting time were performed on:
a.) May 9, 2011 starting at 10:40 a.m.
b.) September 10, 2011 starting at 0705.
c.) October 5, 2011 starting at 0515.
d.) November 17, 2011 starting at 0700.
e.) November 18, 2011 starting at 6:10 a.m.
f.) December 15, 2011 starting at 5:10 a.m.
g.) January 26, 2012 starting at 5:05 a.m.

Diesel-powered emergency generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available load and then subject to a load bank test annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours pet section 6-4.2.2 of NFPA 110.

3. The maintenance logs for the emergency generator were reviewed at the facility on January 30, 2012 and monthly tests were being conducted but no indication was noted at to meeting either method described above in 6-4.2 of NFPA 110. In addition, the initial installation test for the emergency generator dated March 17, 2004 was reviewed that included a load test but did not document if the requirements of 6-4.2 of NFPA 110 were being met. In lieu of such confirmation an annual load test meeting the parameters of 6-4.2.2 of NFPA 110 would be required of the generator and such documentation was not available for 2011.

Emergency generators serving a Type I EES, including all appurtenant components, shall be inspected weekly per section 6-4.1 of NFPA 110.

4. The logs for the emergency generator were reviewed at the facility on January 30, 2012. There was no documentation available that the emergency generator was being inspected on a weekly basis.