HospitalInspections.org

Based on record review and observations, portions of the hospital services are not separated from the Rural Health Clinic by a two hour separation per NFPA 101, 2000 Edition, Section 19.1.2.1. This deficiency would affect patients/residents and staff in one partially sprinklered smoke compartment of eight smoke compartments.

Findings include:

The Critical Access Hospital imaging suite and two procedure rooms are not separated from the B occupancy by two hour construction. The facility currently has a waiver for this requirement which was approved by Centers for Medicare and Medicaid Services (CMS) Regional Office in Denver. On the basis of this waiver, the space housing the imaging and procedure rooms met exiting requirements for a suite, and it was completely sprinklered both on the main floor and basement of the service area in question. The facility also installed smoke detection just on the other side of the clinic door in 2005.

Based on observations and an interview, the facility failed to maintain smoke barrier doors for complete closure and resisting the passage of smoke per NFPA 101, 2000 Edition, Sections 19.3.7.6 and 8.3.4. This deficiency could affect residents, staff, and visitors in two of eight smoke compartments.

Findings include:

1. The smoke barrier doors located in Sweetgrass Way (200 wing) were observed on 7/23/14 at 2:35 p.m. The northeastern door of the set would not close completely as it would bind with the southwestern door. Staff member A, maintenance supervisor, indicated these doors have been sanded previously to close correctly. The edge of the northeastern door had been plained or sanded. ? ?

?NFPA 101 Life Safety Code, 2000 Edition, Section 8.3.4.1, Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

? NFPA 101, 2000 Edition, Annex A.8.3.4.1, The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

Based on observations and interview, the facility failed to maintain egress exit panic hardware per NFPA 101, 2000 Edition, Section 7.2.1.5.1. This deficiency affected one of eight smoke compartments.

Findings include:

1. Sweetgrass Way (100 Wing) was observed on 7/23/14 at 2:52 p.m. A visitor tried to exit through the southwest double doors to the outside. When the visitor pressed the south side door panic bar, the door would not open. The visitor asked staff member A, maintenance supervisor, if there was a code she needed to exit the facility. He indicated the door should open without a code. The visitor tried the north side door and was able to leave the building. The doors were exercised after this, and it was determined that the southside door would not open if pressure was applied to the further left part of the panic bar.?

?NFPA 101 Life Safety Code, 2000 Edition, Section 7.2.1.5.1, Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

Based on record review and interview, the facility failed to perform required testing of battery backup emergency lights per NFPA 101, 2000 Edition, Section 7.9.3. This deficiency could affect any emergency lighting with battery backup throughout the facility in two of eight smoke compartments.

Findings include:

1. The maintenance records for emergency lighting were reviewed at 10:45 a.m. on 7/23/14. When asked if a 90 minute test was conducted for all emergency battery backup lighting, staff member A, maintenance supervisor, stated a 30 second test was done monthly but not an annual test. He further added that the units would only last for one hour on battery power.

?NFPA 101 Life Safety Code, 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment, 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 11/2 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on record review and interview, the facility failed to have an annual fire alarm inspection completed per NFPA 72, 1999 Edition, Section 7-3. This deficiency could affect all residents, staff, and visitors in all eight of eight smoke compartments.

Findings include:

1. The fire alarm records were reviewed at 10:15 a.m. on 7/23/14. There was no annual record for the testing of the fire alarm system. Staff member A, maintenance supervisor, indicated that he could not locate the test for the fire alarm system for 2014. The last report available was March 2013. The testing was almost three months past the testing date. ? ?

2. On 7/24/14 at 7:15 a.m., the annual fire alarm panel testing records were reviewed. The records indicated that the load voltage test on the sealed lead-acid batteries for the fire alarm control panel was conducted once. These tests must be conducted semi-annually.?

At 7:16 a.m., staff member A verified that the load voltage tests were conducted once, annually, by the service contractor. Staff member A also verified that he did not conduct the load voltage tests.

?NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.1 Visual Inspection, Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 months.
Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. Table 7-3.1 shall apply.

?NFPA 72, 1999 Edition, Section 7-3.2 Testing, Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

?NFPA 72, 1999 Edition, Table 7-3.2 (6)(d)(1) & (3).

Based on observation and interview, the facility failed to fully sprinkle all areas per NFPA 101, 2000 Edition, Section 19.1.6.2. This deficiency would affect two of eight smoke compartments.

Findings include:

1. The surgical suite on the 100 wing of the old hospital was observed at 4:05 p.m. on 7/23/14. The operating room lacked sprinkler coverage as verified by the staff member A, maintenance supervisor. ?
2. The north, covered exit near the kitchen was observed on 7/24/14 at 7:30 a.m. The enclosed exit lacked sprinkler protection. Staff member A, maintenance supervisor, indicated a fire retardant paint is added annually to the wooden trim boards. He confirmed the construction is wood interior studs with a gypsum board covering. This would not meet the requirements of noncombustible or limited combustible construction per NFPA 13, Section 5-13.8.1.? ?

?NFPA 101 Life Safety Code, 2000 Edition, Section 19.1.6.2, Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
Table 19.1.6.2 Construction Type Limitations

Construction
Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

?NFPA 13 Standard for the Installation of Sprinkler Systems
1999 Edition, Section 5-13.8.1, Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

?NFPA 13, 1999 Edition, Annex A-5-13.8, Small loading docks, covered platforms, ducts, or similar small unheated areas can be protected by dry-pendent sprinklers extending through the wall from wet sprinkler piping in an adjacent heated area. Where protecting covered platforms, loading docks, and similar areas, a dry-pendent sprinkler should extend down at a 45-degree angle. The width of the area to be protected should not exceed 71/2 ft (2.3 m). Sprinklers should be spaced not over 12 ft (3.7 m) apart. (See Figure A-5-13.8.)
Figure A-5-13.8 Dry-pendent sprinklers for protection of covered platforms, loading docks, and similar areas.

Based on record review and interview, the facility failed to maintain the automatic fire suppression system per NFPA 13, 1999 Edition and NFPA 25, 1998 Edition. These deficiencies could affect all residents, staff, and visitors to the facility and all eight smoke compartments.

Findings include:

1. The last annual automatic sprinkler system inspection dated 5/22/14 was reviewed on 7/23/14. The report contained several "Additional Comments" detailing concerns related to the installed sprinkler system.
a.) The fire department connection check valve was stuck in the closed position. In the event of a fire, the fire department would not be able to energize the sprinkler system with water if the city water failed. This check valve shall be repaired or replaced as required in NFPA 25, 1998, Section 9-4.2.1.
b.) At least two sprinkler heads that were removed by the contractor contained CPVC glue inside the sprinkler orifice. These same sprinklers were installed with a thread dope which had clogged these heads with at least a 90% blockage. Similarly installed sprinkler heads as he above identified shall be included in an internal obstruction investigation as required by NFPA 25, 1998 Edition, Section 10-2. There appear to be different sprinklers heads' manufacturers and dates throughout the facility.
c.) Two sprinkler heads in the old hospital building waiting room were within six feet of each other. This is a deficiency of NFPA 13, 1999 Edition, Section 5-6.3.4. Pendent sprinklers shall be a minimum distance of six feet from each other.
d.) One sprinkler needs to relocated in the nurses' office behind the tub room by the main nurses station. The sprinkler deflector orientation is not parallel to the ceiling assemble contrary to NFPA 13, 1999 Edition, Section 5-6.4.2. Pendent sprinklers shall be a minimum distance of six feet from each other.
e.) One sprinkler needs to be removed in room 312 because there are two sprinklers within six feet of each other. This is a deficiency based of NFPA 13, 1999 Edition, 5-6.3.4. Pendent sprinklers shall be a minimum distance of six feet from each other.
f.) Another sprinkler is required in the entry to Buker Boulevard (300 wing). New signs were added for each wing and the sign hangs down from the hallway header about 14.5 inches. This is a deficiency based on NFPA 13, 1999 Edition, Section 5-6.5.1.2. Obstructions hanging from the ceiling shall not obstruct the sprinkler discharge.
g.) One sprinkler needs to be added in kitchen storage. This is a deficiency based on the room "L Shaped" configuration and the location of current sprinkler.
h.) One head needs to be relocated in the laundry room because there are two sprinklers within six feet of each other. This is a deficiency based of NFPA 13, 1999 Edition, 5-6.3.4. Pendent sprinklers shall be a minimum distance of six feet from each other.
i.) There is one recalled sidewall sprinkler in the laundry room mechanical space behind the gas fired dryers that needs to be replaced.
g.) One sprinkler needs to be added in the break room. This is a deficiency based on the room "L Shaped" configuration and the location of current sprinkler.

2. The 5/22/14 automatic sprinkler report on page 5 of 6, under 14. Explanation of Deficiencies. (Sections 2 thru 13), includes a comment about "SOME QUICK RESPONSE SPRINKLERS WILL BE EXPIRED IN 2014 AND WILL NEED TO BE REPLACED OR TESTED IN 2014. THESE ARE 1994 SPRINKLERS THAT ARE ONLY GOOD FOR 20 YEARS."

3. A laundry room was reviewed on 7/23/14 at 1:25 p.m. A housekeeping closet contained a wall mounted shelf which was within 18 inches of the pendent sprinkler mounted directly above it. This is a deficiency based on NFPA 13, 1999 Edition, Section 5-5.6 Clearance to Storage.

Based on observation and interview, the facility failed to locate electrical fixtures at the proper height and to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Sections 8.31.11.2 and 4-3.1.1.2. This deficiency could affect residents, visitors, and staff inside one of eight smoke compartments and all staff accessing outside oxygen storage area.

Findings include:

1. The inside oxygen storage room on Sweetgrass Way (100 wing) was observed at 2:52 p.m. on 7/23/14. The room contained less than 3000 cubic feet of oxygen, but the room electrical fixture (a light switch) was not mounted at at least 60 inches.?

2. The outside oxygen storage area was observed on 7/23/14 at 4:30 p.m. The area contained well over 3000 cubic feet of compressed oxygen. One oxygen compressed gas nitrous oxide cylinder had been returned to the outside storage and had not been put in a rack or properly secured.? Staff member A, maintenance director, did not know the origin of the nitrous oxide container, but assumed it had come from the dentist's office in the Rural Health Clinic.

3. The outside oxygen gas manifold system for the CAH and NH was reviewed at 4:30 p.m. The larger, approximately five feet tall liquid oxygen containers were not restrained from falling although at least three of them were connected to the manifold system as the primary oxygen supply.?

?NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 8-3.1.11.2, Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

?NFPA 99, 1999 Edition, Section 4-3.1.1.2, Storage Requirements (Location, Construction, Arrangement). (a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
2. Nitrous oxide supply systems or storage locations having a total capacity of 3200 lb (1452 kg) [28,000 ft3 (793 m3) (NTP)] or more, including unconnected reserves on hand at the site, shall comply with CGA Pamphlet G-8.1, Standard for the Installation of Nitrous Oxide Systems at Consumer Sites.
3. The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

Based on observation and interview, the medical gas shut off valves were not appropriately labeled to indicate the room they were controlling per NFPA 99, 2000 Edition, Section 4-3.1.2.3(m). This could affect all patients and staff in critical care areas in three of eight smoke compartments.

Findings include:

1. The facility was toured from 12:30 p.m. until 4:50 p.m. on 7/23/14. A number of medical gas shut off valves were reviewed for labeling. Many of the valves were not labeled to reflect changes in use of critical care areas and designation of the room. Staff member A, maintenance supervisor, stated many of shut off valves were not updated to reflect the correct room they controlled.? ?

?NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.1.2.3 (m), Shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

?NFPA 99, 1999 Edition, Section 4-3.5.4.2, The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, the facility failed to assure proper signage was posted in storage areas used for oxygen or oxidizing gasses per NFPA 99, Section 8.3.1.11.3. The deficiency could affect all staff or contractors who access the area for maintenance purposes.

Findings include:

1. On 7/23/14 at 4:30 p.m., the manifold system for the piped oxygen was observed for proper signage. There was no sign on the outside of the gated area indicating oxygen was stored within.?

?NFPA 99, 1999 Edition, Section 8-3.1.11.3, A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and interview, the facility failed to document a weekly visual inspection of the emergency generator per NFPA 110, 1999 Edition, Sections 6-3.1 and 6-4.1. This deficiency could affect all the occupants in the facility and eight of eight smoke compartments.

Findings include:

1. The generator test records were reviewed on 7/23/14. The monthly load tests were current and documented, but documentation was not available for the weekly visual inspections.? Staff member A, maintenance supervisor, confirmed at 4:55 p.m. he did not perform weekly inspections on the electrolyte levels in the batteries which serve to start the generator transfer switch connections for overheating and excessive contact erosion, dust, etc. A weekly review of the generator should be and documented.? ?

?NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-3.1, The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. Annex A-6-3.1 The suggested maintenance procedure and frequency should follow those recommended by the manufacturer. In the absence of such recommendations, the Figures A-6-3.1(a) and (b) indicate alternate suggested procedures. [See Figures A-6-3.1(a) and (b).]

?NFPA 110, 1999 Edition, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Based on observations and interview, the facility failed to provide a working and properly located remote annunciator for the emergency generator per NFPA 99, 1999 Edition, Section 3-4.1.1.15 and NFPA 110, 1999 Edition, Section 3-5.6.1. These deficiencies could affect all residents, staff, visitors in all eight smoke compartments.

The findings include:

1. The Caterpillar brand 125 kilowatt emergency generator and remote annunciator serving the facility were examined on 7/14/14 at 4:09 p.m.
a.) The remote annunciator failed upon testing, as no lights or alarms sounded.? Staff member A, maintenance director, confirmed this was the only remote annunciator for the generator in the facility and that it failed to work when tested.
b.) The remote annunciator was in the old hospital building surgery suite which is not a 24-hour a day observed area?.? Staff member A indicated that the remote annunciator was audible if one was walking down the old hospital corridor, but he indicated that this area is not normally occupied by staff.

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

?NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 3-5.6.1,
A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

Based on review of the fire watch policy, the facility fire watch policy lacked contacting the Certification Bureau when the automatic sprinkler system was out of service for more than 4 hours in a 24 hour period per NFPA 101, 2000 Edition, Section 9.7.6.1, and the fire watch was initiated. This deficiency has the potential to affect all residents, staff, and visitors in all eight smoke compartments.

Findings include:

The fire policy was reviewed on 7/23/14 at 10:30 a.m. The present policy did not include contacting the Certification Bureau at 406-444-4170 and notifying when the automatic sprinkler system was out of service for more than 4 hours in a 24 hour period.

Based on review of the fire watch policy, the facility fire watch policy lacked contacting the Certification Bureau whenever a fire watch was instituted after the fire alarm system was out of service for more than 4 hours in a 24 hour period per NFPA 101, Section 9.6.1.8. This deficiency has the potential to affect all residents, staff, and visitors in all eight smoke compartments.

Findings include:

The fire policy was reviewed on 7/24/14 at 10:30 a.m. The present policy did not include contacting the Certification Bureau at 406-444-4170 and notifying when the fire alarm system was out of service for more than 4 hours in a 24 hour period.

Based on record review and observations, portions of the hospital services are not separated from the Rural Health Clinic by a two hour separation per NFPA 101, 2000 Edition, Section 19.1.2.1. This deficiency would affect patients/residents and staff in one partially sprinklered smoke compartment of eight smoke compartments.

Findings include:

The Critical Access Hospital imaging suite and two procedure rooms are not separated from the B occupancy by two hour construction. The facility currently has a waiver for this requirement which was approved by Centers for Medicare and Medicaid Services (CMS) Regional Office in Denver. On the basis of this waiver, the space housing the imaging and procedure rooms met exiting requirements for a suite, and it was completely sprinklered both on the main floor and basement of the service area in question. The facility also installed smoke detection just on the other side of the clinic door in 2005.

Based on observations and an interview, the facility failed to maintain smoke barrier doors for complete closure and resisting the passage of smoke per NFPA 101, 2000 Edition, Sections 19.3.7.6 and 8.3.4. This deficiency could affect residents, staff, and visitors in two of eight smoke compartments.

Findings include:

1. The smoke barrier doors located in Sweetgrass Way (200 wing) were observed on 7/23/14 at 2:35 p.m. The northeastern door of the set would not close completely as it would bind with the southwestern door. Staff member A, maintenance supervisor, indicated these doors have been sanded previously to close correctly. The edge of the northeastern door had been plained or sanded. ? ?

?NFPA 101 Life Safety Code, 2000 Edition, Section 8.3.4.1, Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

? NFPA 101, 2000 Edition, Annex A.8.3.4.1, The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

Based on observations and interview, the facility failed to maintain egress exit panic hardware per NFPA 101, 2000 Edition, Section 7.2.1.5.1. This deficiency affected one of eight smoke compartments.

Findings include:

1. Sweetgrass Way (100 Wing) was observed on 7/23/14 at 2:52 p.m. A visitor tried to exit through the southwest double doors to the outside. When the visitor pressed the south side door panic bar, the door would not open. The visitor asked staff member A, maintenance supervisor, if there was a code she needed to exit the facility. He indicated the door should open without a code. The visitor tried the north side door and was able to leave the building. The doors were exercised after this, and it was determined that the southside door would not open if pressure was applied to the further left part of the panic bar.?

?NFPA 101 Life Safety Code, 2000 Edition, Section 7.2.1.5.1, Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

Based on record review and interview, the facility failed to perform required testing of battery backup emergency lights per NFPA 101, 2000 Edition, Section 7.9.3. This deficiency could affect any emergency lighting with battery backup throughout the facility in two of eight smoke compartments.

Findings include:

1. The maintenance records for emergency lighting were reviewed at 10:45 a.m. on 7/23/14. When asked if a 90 minute test was conducted for all emergency battery backup lighting, staff member A, maintenance supervisor, stated a 30 second test was done monthly but not an annual test. He further added that the units would only last for one hour on battery power.

?NFPA 101 Life Safety Code, 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment, 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 11/2 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on record review and interview, the facility failed to have an annual fire alarm inspection completed per NFPA 72, 1999 Edition, Section 7-3. This deficiency could affect all residents, staff, and visitors in all eight of eight smoke compartments.

Findings include:

1. The fire alarm records were reviewed at 10:15 a.m. on 7/23/14. There was no annual record for the testing of the fire alarm system. Staff member A, maintenance supervisor, indicated that he could not locate the test for the fire alarm system for 2014. The last report available was March 2013. The testing was almost three months past the testing date. ? ?

2. On 7/24/14 at 7:15 a.m., the annual fire alarm panel testing records were reviewed. The records indicated that the load voltage test on the sealed lead-acid batteries for the fire alarm control panel was conducted once. These tests must be conducted semi-annually.?

At 7:16 a.m., staff member A verified that the load voltage tests were conducted once, annually, by the service contractor. Staff member A also verified that he did not conduct the load voltage tests.

?NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.1 Visual Inspection, Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 months.
Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. Table 7-3.1 shall apply.

?NFPA 72, 1999 Edition, Section 7-3.2 Testing, Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

?NFPA 72, 1999 Edition, Table 7-3.2 (6)(d)(1) & (3).

Based on observation and interview, the facility failed to fully sprinkle all areas per NFPA 101, 2000 Edition, Section 19.1.6.2. This deficiency would affect two of eight smoke compartments.

Findings include:

1. The surgical suite on the 100 wing of the old hospital was observed at 4:05 p.m. on 7/23/14. The operating room lacked sprinkler coverage as verified by the staff member A, maintenance supervisor. ?
2. The north, covered exit near the kitchen was observed on 7/24/14 at 7:30 a.m. The enclosed exit lacked sprinkler protection. Staff member A, maintenance supervisor, indicated a fire retardant paint is added annually to the wooden trim boards. He confirmed the construction is wood interior studs with a gypsum board covering. This would not meet the requirements of noncombustible or limited combustible construction per NFPA 13, Section 5-13.8.1.? ?

?NFPA 101 Life Safety Code, 2000 Edition, Section 19.1.6.2, Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
Table 19.1.6.2 Construction Type Limitations

Construction
Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

?NFPA 13 Standard for the Installation of Sprinkler Systems
1999 Edition, Section 5-13.8.1, Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

?NFPA 13, 1999 Edition, Annex A-5-13.8, Small loading docks, covered platforms, ducts, or similar small unheated areas can be protected by dry-pendent sprinklers extending through the wall from wet sprinkler piping in an adjacent heated area. Where protecting covered platforms, loading docks, and similar areas, a dry-pendent sprinkler should extend down at a 45-degree angle. The width of the area to be protected should not exceed 71/2 ft (2.3 m). Sprinklers should be spaced not over 12 ft (3.7 m) apart. (See Figure A-5-13.8.)
Figure A-5-13.8 Dry-pendent sprinklers for protection of covered platforms, loading docks, and similar areas.

Based on record review and interview, the facility failed to maintain the automatic fire suppression system per NFPA 13, 1999 Edition and NFPA 25, 1998 Edition. These deficiencies could affect all residents, staff, and visitors to the facility and all eight smoke compartments.

Findings include:

1. The last annual automatic sprinkler system inspection dated 5/22/14 was reviewed on 7/23/14. The report contained several "Additional Comments" detailing concerns related to the installed sprinkler system.
a.) The fire department connection check valve was stuck in the closed position. In the event of a fire, the fire department would not be able to energize the sprinkler system with water if the city water failed. This check valve shall be repaired or replaced as required in NFPA 25, 1998, Section 9-4.2.1.
b.) At least two sprinkler heads that were removed by the contractor contained CPVC glue inside the sprinkler orifice. These same sprinklers were installed with a thread dope which had clogged these heads with at least a 90% blockage. Similarly installed sprinkler heads as he above identified shall be included in an internal obstruction investigation as required by NFPA 25, 1998 Edition, Section 10-2. There appear to be different sprinklers heads' manufacturers and dates throughout the facility.
c.) Two sprinkler heads in the old hospital building waiting room were within six feet of each other. This is a deficiency of NFPA 13, 1999 Edition, Section 5-6.3.4. Pendent sprinklers shall be a minimum distance of six feet from each other.
d.) One sprinkler needs to relocated in the nurses' office behind the tub room by the main nurses station. The sprinkler deflector orientation is not parallel to the ceiling assemble contrary to NFPA 13, 1999 Edition, Section 5-6.4.2. Pendent sprinklers shall be a minimum distance of six feet from each other.
e.) One sprinkler needs to be removed in room 312 because there are two sprinklers within six feet of each other. This is a deficiency based of NFPA 13, 1999 Edition, 5-6.3.4. Pendent sprinklers shall be a minimum distance of six feet from each other.
f.) Another sprinkler is required in the entry to Buker Boulevard (300 wing). New signs were added for each wing and the sign hangs down from the hallway header about 14.5 inches. This is a deficiency based on NFPA 13, 1999 Edition, Section 5-6.5.1.2. Obstructions hanging from the ceiling shall not obstruct the sprinkler discharge.
g.) One sprinkler needs to be added in kitchen storage. This is a deficiency based on the room "L Shaped" configuration and the location of current sprinkler.
h.) One head needs to be relocated in the laundry room because there are two sprinklers within six feet of each other. This is a deficiency based of NFPA 13, 1999 Edition, 5-6.3.4. Pendent sprinklers shall be a minimum distance of six feet from each other.
i.) There is one recalled sidewall sprinkler in the laundry room mechanical space behind the gas fired dryers that needs to be replaced.
g.) One sprinkler needs to be added in the break room. This is a deficiency based on the room "L Shaped" configuration and the location of current sprinkler.

2. The 5/22/14 automatic sprinkler report on page 5 of 6, under 14. Explanation of Deficiencies. (Sections 2 thru 13), includes a comment about "SOME QUICK RESPONSE SPRINKLERS WILL BE EXPIRED IN 2014 AND WILL NEED TO BE REPLACED OR TESTED IN 2014. THESE ARE 1994 SPRINKLERS THAT ARE ONLY GOOD FOR 20 YEARS."

3. A laundry room was reviewed on 7/23/14 at 1:25 p.m. A housekeeping closet contained a wall mounted shelf which was within 18 inches of the pendent sprinkler mounted directly above it. This is a deficiency based on NFPA 13, 1999 Edition, Section 5-5.6 Clearance to Storage.

Based on observation and interview, the facility failed to locate electrical fixtures at the proper height and to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Sections 8.31.11.2 and 4-3.1.1.2. This deficiency could affect residents, visitors, and staff inside one of eight smoke compartments and all staff accessing outside oxygen storage area.

Findings include:

1. The inside oxygen storage room on Sweetgrass Way (100 wing) was observed at 2:52 p.m. on 7/23/14. The room contained less than 3000 cubic feet of oxygen, but the room electrical fixture (a light switch) was not mounted at at least 60 inches.?

2. The outside oxygen storage area was observed on 7/23/14 at 4:30 p.m. The area contained well over 3000 cubic feet of compressed oxygen. One oxygen compressed gas nitrous oxide cylinder had been returned to the outside storage and had not been put in a rack or properly secured.? Staff member A, maintenance director, did not know the origin of the nitrous oxide container, but assumed it had come from the dentist's office in the Rural Health Clinic.

3. The outside oxygen gas manifold system for the CAH and NH was reviewed at 4:30 p.m. The larger, approximately five feet tall liquid oxygen containers were not restrained from falling although at least three of them were connected to the manifold system as the primary oxygen supply.?

?NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 8-3.1.11.2, Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

?NFPA 99, 1999 Edition, Section 4-3.1.1.2, Storage Requirements (Location, Construction, Arrangement). (a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
2. Nitrous oxide supply systems or storage locations having a total capacity of 3200 lb (1452 kg) [28,000 ft3 (793 m3) (NTP)] or more, including unconnected reserves on hand at the site, shall comply with CGA Pamphlet G-8.1, Standard for the Installation of Nitrous Oxide Systems at Consumer Sites.
3. The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

Based on observation and interview, the medical gas shut off valves were not appropriately labeled to indicate the room they were controlling per NFPA 99, 2000 Edition, Section 4-3.1.2.3(m). This could affect all patients and staff in critical care areas in three of eight smoke compartments.

Findings include:

1. The facility was toured from 12:30 p.m. until 4:50 p.m. on 7/23/14. A number of medical gas shut off valves were reviewed for labeling. Many of the valves were not labeled to reflect changes in use of critical care areas and designation of the room. Staff member A, maintenance supervisor, stated many of shut off valves were not updated to reflect the correct room they controlled.? ?

?NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.1.2.3 (m), Shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

?NFPA 99, 1999 Edition, Section 4-3.5.4.2, The shutoff valves described in 4-3.1.2.3, 4-3.1.2.3(m), and 4-3.1.2.3(n) shall be labeled to reflect the rooms that are controlled by such valves. Labeling shall be kept current from initial construction through acceptance. Valves shall be labeled in substance as follows:
CAUTION:
(NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

Based on observation, the facility failed to assure proper signage was posted in storage areas used for oxygen or oxidizing gasses per NFPA 99, Section 8.3.1.11.3. The deficiency could affect all staff or contractors who access the area for maintenance purposes.

Findings include:

1. On 7/23/14 at 4:30 p.m., the manifold system for the piped oxygen was observed for proper signage. There was no sign on the outside of the gated area indicating oxygen was stored within.?

?NFPA 99, 1999 Edition, Section 8-3.1.11.3, A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and interview, the facility failed to document a weekly visual inspection of the emergency generator per NFPA 110, 1999 Edition, Sections 6-3.1 and 6-4.1. This deficiency could affect all the occupants in the facility and eight of eight smoke compartments.

Findings include:

1. The generator test records were reviewed on 7/23/14. The monthly load tests were current and documented, but documentation was not available for the weekly visual inspections.? Staff member A, maintenance supervisor, confirmed at 4:55 p.m. he did not perform weekly inspections on the electrolyte levels in the batteries which serve to start the generator transfer switch connections for overheating and excessive contact erosion, dust, etc. A weekly review of the generator should be and documented.? ?

?NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-3.1, The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. Annex A-6-3.1 The suggested maintenance procedure and frequency should follow those recommended by the manufacturer. In the absence of such recommendations, the Figures A-6-3.1(a) and (b) indicate alternate suggested procedures. [See Figures A-6-3.1(a) and (b).]

?NFPA 110, 1999 Edition, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Based on observations and interview, the facility failed to provide a working and properly located remote annunciator for the emergency generator per NFPA 99, 1999 Edition, Section 3-4.1.1.15 and NFPA 110, 1999 Edition, Section 3-5.6.1. These deficiencies could affect all residents, staff, visitors in all eight smoke compartments.

The findings include:

1. The Caterpillar brand 125 kilowatt emergency generator and remote annunciator serving the facility were examined on 7/14/14 at 4:09 p.m.
a.) The remote annunciator failed upon testing, as no lights or alarms sounded.? Staff member A, maintenance director, confirmed this was the only remote annunciator for the generator in the facility and that it failed to work when tested.
b.) The remote annunciator was in the old hospital building surgery suite which is not a 24-hour a day observed area?.? Staff member A indicated that the remote annunciator was audible if one was walking down the old hospital corridor, but he indicated that this area is not normally occupied by staff.

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

?NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 3-5.6.1,
A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

Based on review of the fire watch policy, the facility fire watch policy lacked contacting the Certification Bureau when the automatic sprinkler system was out of service for more than 4 hours in a 24 hour period per NFPA 101, 2000 Edition, Section 9.7.6.1, and the fire watch was initiated. This deficiency has the potential to affect all residents, staff, and visitors in all eight smoke compartments.

Findings include:

The fire policy was reviewed on 7/23/14 at 10:30 a.m. The present policy did not include contacting the Certification Bureau at 406-444-4170 and notifying when the automatic sprinkler system was out of service for more than 4 hours in a 24 hour period.

Based on review of the fire watch policy, the facility fire watch policy lacked contacting the Certification Bureau whenever a fire watch was instituted after the fire alarm system was out of service for more than 4 hours in a 24 hour period per NFPA 101, Section 9.6.1.8. This deficiency has the potential to affect all residents, staff, and visitors in all eight smoke compartments.

Findings include:

The fire policy was reviewed on 7/24/14 at 10:30 a.m. The present policy did not include contacting the Certification Bureau at 406-444-4170 and notifying when the fire alarm system was out of service for more than 4 hours in a 24 hour period.