HospitalInspections.org

Based on observations made on July 12, 2010, the facility failed to maintain the two-hour fire resistance rating of the fire barrier between the Critical Access Hospital and the adjoining Meadowlark Assisted Living building.

The findings include:

Two open-faced conduit being used as a pass-through for wiring in the two-hour barrier between the Critical Access Hospital and the Meadowlark building in the ceiling area above the men's restroom were observed to be unsealed at 3:37 p.m. on July 12, 2010. These must be sealed with a fire rated material to maintain the two-hour fire barrier.

Based on observations made on July 12, 2010, the facility failed to maintain the fire resistant rating of wall and structural components in a building of Type V (111) construction.

The findings include:

1. A section of the lower wall assembly in the wheelchair storage room accessed off of the Ambulance entry corridor had deteriorated as observed at 11:50 a.m. on July 12, 2010. The deterioration resulted in an opening completely through the lathe and plaster wall that was not sealed to maintain the fire resistant rating of this assembly.

2. Two portions of the eaves at the 4th Avenue North entrance area were deteriorating as observed at 12:38 p.m. on July 12, 2010. The deterioration resulted in wood members of the structural support beams being exposed and unprotected. The two areas were:
a) The corner of the eave directly above the entry doors, and
b) A portion of the eave immediately to the west of the entry doors.

3. A portion of a wall assembly in the staff break room had wood slats exposed as observed at 3:10 p.m. on July 12, 2010. The wood slats were in the wall area around plumbing fixtures that protruded through the wall assembly. There was no non-combustible cover or finish over this wood to maintain the fire resistant rating of the assembly.

Based on observations made on July 12, 2010, the facility failed to assure that a corridor door was provided with a means suitable for keeping the door closed.

The findings include:

The corridor door to room 2 was exercised at 2:50 p.m. on July 12, 2010. The door did not close and latch due to binding on the frame.

Based on observations made on July 12, 2010, the facility failed to assure that at least two acceptable exits are provided from each section of the building.

The findings include:

The basement area of the Critical Access Hospital (CAH) that adjoins the Meadowlark Assisted Living building had two means of egress available as observed at 3:30 p.m. on July 12, 2010. One means was through a horizontal exit to the Meadowlark building. The other means was a stairway from the basement to the main level of the CAH. The stairway was not an acceptable exit due to the lack of a fire-rated exit passageway leading to the public way from the stairway landing on the main level.

Based on observations made on July 12, 2010, the facility failed to assure that vertical openings such as exit stairways are enclosed at each level by fire resistant construction.

The findings include:

The basement area of the Critical Access Hospital (CAH) that adjoins the Meadowlark Assisted Living building had a stairway from the basement to the main level as observed at 3:30 p.m. on July 12, 2010. The stairway was separated at the basement level by fire doors and walls. The stairway at the main level was not separated from the corridor system by fire rated-construction.

Based on observations made on July 12, 2010, the facility failed to assure that swinging doors used as exits could be opened with 30 pounds of force or less.

The findings include:

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion, and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the Life Safety Code. These forces shall be applied at the latch stile.

The exit door from the basement boiler room was exercised at 1:52 p.m. on July 12, 2010. While the latch did release, the door did not swing open with at least 30 pounds of force being applied at the latch stile due to the binding of the door with the lower portion of the frame.

Based on observations made on July 12, 2010, the facility failed to assure that at least 1 foot-candle of light was available at the floor level in any exit corridor for purposes of illumination.

The findings include:

Illumination of means of egress, including corridors, shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values specified per section 7.8.2.1 of the Life Safety Code. The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge shall be illuminated to values of at least 1 foot-candle measured at the floor level per 7.8.1.3 of the Life Safety Code.

1. The corridor lights on the west wing were tested at 2:30 p.m. on July 12, 2010. When the overhead lights in the corridor were shut off the wall mounted lights intended to provide at least 1 foot-candle of illumination for egress purposes did not come on, possibly due to burned out bulbs.

2. The corridor lights on the east wing were tested at 2:41 p.m. on July 12, 2010. When the overhead lights in the corridor were shut off the wall mounted lights intended to provide at least 1 foot-candle of illumination for egress purposes did not come on, possibly due to burned out bulbs.

Based on observations made on July 12, 2010, the facility failed to assure that the battery-powered emergency light located in the room housing the generator was fully functional.

The findings include:

The Level 1 or Level 2 EPS equipment (being the emergency generator) location 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 battery-powered emergency light located in the generator room was tested at 1:57 p.m. on July 12, 2010. The light did not illuminate when the test button on the fixture was exercised.

Based on review of the fire drill reports at the facility on July 12, 2010, the facility failed to assure that the remote monitoring agency for its fire alarm system was automatically notifying the local fire department whenever a fire alarm was transmitted to it without prior knowledge or approval.

The findings include:

Emergency forces notification shall be provided to alert the municipal fire department of fire or other emergency per 9.6.4 of the Life Safety Code. The fire alarm system shall be arranged to transmit the alarm automatically per section 19.3.4.3.2 of the Life Safety Code via a remote or central station connection. The central station will immediately retransmit the alarm to the public fire service communications center and notify the subscriber of such action per sections 5-2.6.1.1 and 5-4.3.1 of NFPA 72, 1999 edition.

The fire drill reports were reviewed at the facility on July 12, 2010. The drills dated March 28, 2009 and March 30, 2009 both noted that the monitoring company had called the facility to verify if the fire department needed to be dispatched. Although these were drills, the monitoring company if not notified prior to the fire drill, must treat any alarm as a fire condition and automatically notify the fire department. The monitoring company may call the subscriber, in this case the facility, after the fire department has been notified to confirm if a fire exist or if the fire department may be cancelled. The facility must assure that its contract with the alarm monitoring company includes the automatic, and first, notification to the fire department.

Based on observations made on July 12, 2010, the facility failed to provide for sprinkler protection for a canopy exceeding 4 feet in width.

The findings include:

Sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 feet in width per section 5-13.8.1 of NFPA 13, 1999 edition.

The building is of Type V (111) construction and requires that it be protected by a complete automatic sprinkler system. Canopies over 4 feet in width in this type of construction are required to be protected by the sprinkler system. The canopy at the exit discharge from the basement laundry room stairway was measured at 5 feet 9 inches in width at 1:40 p.m. on July 12, 2010. There was no sprinkler protecting this canopy assembly. Note: No items of any nature, whether combustible or not, were stored or placed under this canopy at the time the observation was made.

Based on observations made on July 12, 2010, the facility failed to provide for electronic supervision of a control valve for the sprinkler system.

The findings include:

Where supervised automatic sprinkler systems are required, supervisory attachments shall be installed and electronically monitored for integrity in accordance with NFPA 72, 1999 edition per section 9.7.2.1 of the Life Safety Code. Monitoring shall include, but shall not be limited to, monitoring of control valves.

The kitchen range and hood are protected by the automatic fire sprinkler extinguishing system as observed at 3:00 p.m. on July 12, 2010. The shut-off valve for servicing the sprinklers was observed to have a chain and a padlock in place as the means for securing the valve against being shut-off by unauthorized persons. The shut-off valve was not electronically supervised to sound at least a local alarm or interconnected to the fire alarm control panel.

Based on review of the sprinkler service reports on July 12, 2010, the facility failed to assure that the fuel shut-off valve for the kitchen range was tested and maintained.

The findings include:

Upon activation of any fire-extinguishing system for a cooking operation, all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off per section 7-4.1 of NFPA 96, 1998 edition. All shut off devices shall require manual reset.

The kitchen range and hood are protected by the automatic fire sprinkler extinguishing system as observed at 2:58 p.m. on July 12, 2010. The sprinkler contractor reports dated September 5, 2007 and December 6, 2007, noted that the fuel shut-off interconnected to this sprinkler control had been tested at the time of those inspections. In reviewing the remainder of the sprinkler contractor and fire alarm reports since those dates noted above, there has been no mention or verification that the shut-off control had been tested and manually reset to assure its reliability in case of fire.

Based on observations made on July 12, 2010, the facility failed to assure that the self-closing mechanism on a linen chute door provided sufficient force to close and latch the door.

The findings include:

All chute loading doors into a linen chute shall be provided with a self-closing, positive-latching frame and gasketed fire door assembly approved for Class B openings and having a rating of not less than 1 hour per section 3-2.4.2 of NFPA 82, 1999 edition.

The fire rated linen chute door located in the basement soiled linen room was exercised at 2:04 p.m. on July 12, 2010. The self-closing mechanism on the door (spring loaded) did not exert sufficient force to close and latch the chute door.

Based on observations made on July 12, 2010, the facility failed to prevent items from being stored in an exit corridor unattended for periods exceeding 30 minutes.

The findings include:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18.

An exit corridor exists from the CT Scan and Procedure room suites with a set of traffic control doors near the Admission's desk. The set of traffic control doors did not have latching hardware. A wheeled assembly containing three hampers, a wheeled scale, a wheeled laundry cart frame and a portable X-Ray machine were observed to be parked in the exit corridor initially at 1:35 p.m. on July 12, 2010. The hampers were removed, but the other items were still in the exit corridor as observed at both 2:05 p.m. and 3:30 p.m. on July 12, 2010. Items can not be stored or left in the exit corridor if unattended for more than 30 minutes.

Based on observations made on July 12, 2010, the facility failed to provide documentation that all fabric curtains, valances and cubicle curtains were flame resistant in accordance with NFPA 701, 1999 edition.

The findings include:

1. A pink cubicle curtain was in use in the Mammography room as observed at 1:20 p.m. on July 12, 2010. The curtain did not have a tag on it attesting to its fire resistant properties or any documentation that it had been treated with a flame retardant made for fabric application.

2. Blue colored hanging curtains were hung on a wall in the Social Services office as observed at 2:35 p.m. on July 12, 2010. The curtains did not have tags on them attesting to their fire resistant properties or any documentation that they had been treated with a flame retardant made for fabric application.

3. Three window curtains were in use in the Special Care Unit (SCU) room as observed at 2:43 p.m. on July 12, 2010. The curtains did not have tags on them attesting to their fire resistant properties or any documentation that they had been treated with a flame retardant made for fabric application.

4. Valances were hung at the windows in the dining room as observed at 3:04 p.m. on July 12, 2010. The valances did not have tags on them attesting to their fire resistant properties or any documentation that they had been treated with a flame retardant made for fabric application.

Based on observations made on July 12, 2010, the facility failed to properly identify the locations served by each oxygen shut-off valve.

The findings include:

Shutoff valves for medical gases including oxygen shall be labeled to reflect the rooms that are controlled by such valves per section 4-3.5.4.2 of NFPA 99, 1999 edition.

1. The oxygen shut-off valve for the room now housing the CT Scan machine was examined at 1:30 p.m. on July 12, 2010. The listing on the shut-off valve showed that it for the "OR" instead of for the CT room. The CT room formerly was the OR and the listing on this shut-off valve must be updated to reflect the change of use or name of the room.

2. The oxygen shut-off valve located at the nurse's station was examined at 2:38 p.m. on July 12, 2010. There was no listing at this valve as to the room or rooms serviced by that valve.

Based on observations and review of fire alarm service reports made on July 12, 2010, the facility failed to provide documentation that the fusible link fire dampers had been tested every 4 years.

The findings include:

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, 1999 edition. Fusible links shall be replaced if they are found to be broken or damaged.

The two-hour fire wall between the Critical Access Hospital and the Meadowlark Assisted Living building was examined at 3:37 p.m. on July 12, 2010. Two ventilation ducts pass through this fire barrier above the men's restroom. It was confirmed that each of these ducts had a fusible link fire damper in them. There was no documentation that the fusible link assemblies had been tested on a 4-year rotation.

Based on observations made on July 12, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip.

A window air conditioner was plugged into a power strip in the Mammography room as observed at 1:20 p.m. on July 12, 2010.

Based on review of the fire policies and procedures of the facility on July 12, 2010, the facility failed to implement requirements for fire watches or evacuation whenever the fire sprinkler system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on July 12, 2010. The policies or procedures did not include safety measures to be taken when the fire sprinkler system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.7.6.1 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building.

Based on review of the fire policies and procedures of the facility on July 12, 2010, the facility failed to implement requirements for fire watches or evacuation whenever the fire alarm system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on July 12, 2010. The policies or procedures did not include safety measures to be taken when the fire alarm system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.6.1.8 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building.

Based on observations made on July 12, 2010, the facility failed to maintain the two-hour fire resistance rating of the fire barrier between the Critical Access Hospital and the adjoining Meadowlark Assisted Living building.

The findings include:

Two open-faced conduit being used as a pass-through for wiring in the two-hour barrier between the Critical Access Hospital and the Meadowlark building in the ceiling area above the men's restroom were observed to be unsealed at 3:37 p.m. on July 12, 2010. These must be sealed with a fire rated material to maintain the two-hour fire barrier.

Based on observations made on July 12, 2010, the facility failed to maintain the fire resistant rating of wall and structural components in a building of Type V (111) construction.

The findings include:

1. A section of the lower wall assembly in the wheelchair storage room accessed off of the Ambulance entry corridor had deteriorated as observed at 11:50 a.m. on July 12, 2010. The deterioration resulted in an opening completely through the lathe and plaster wall that was not sealed to maintain the fire resistant rating of this assembly.

2. Two portions of the eaves at the 4th Avenue North entrance area were deteriorating as observed at 12:38 p.m. on July 12, 2010. The deterioration resulted in wood members of the structural support beams being exposed and unprotected. The two areas were:
a) The corner of the eave directly above the entry doors, and
b) A portion of the eave immediately to the west of the entry doors.

3. A portion of a wall assembly in the staff break room had wood slats exposed as observed at 3:10 p.m. on July 12, 2010. The wood slats were in the wall area around plumbing fixtures that protruded through the wall assembly. There was no non-combustible cover or finish over this wood to maintain the fire resistant rating of the assembly.

Based on observations made on July 12, 2010, the facility failed to assure that a corridor door was provided with a means suitable for keeping the door closed.

The findings include:

The corridor door to room 2 was exercised at 2:50 p.m. on July 12, 2010. The door did not close and latch due to binding on the frame.

Based on observations made on July 12, 2010, the facility failed to assure that at least two acceptable exits are provided from each section of the building.

The findings include:

The basement area of the Critical Access Hospital (CAH) that adjoins the Meadowlark Assisted Living building had two means of egress available as observed at 3:30 p.m. on July 12, 2010. One means was through a horizontal exit to the Meadowlark building. The other means was a stairway from the basement to the main level of the CAH. The stairway was not an acceptable exit due to the lack of a fire-rated exit passageway leading to the public way from the stairway landing on the main level.

Based on observations made on July 12, 2010, the facility failed to assure that vertical openings such as exit stairways are enclosed at each level by fire resistant construction.

The findings include:

The basement area of the Critical Access Hospital (CAH) that adjoins the Meadowlark Assisted Living building had a stairway from the basement to the main level as observed at 3:30 p.m. on July 12, 2010. The stairway was separated at the basement level by fire doors and walls. The stairway at the main level was not separated from the corridor system by fire rated-construction.

Based on observations made on July 12, 2010, the facility failed to assure that swinging doors used as exits could be opened with 30 pounds of force or less.

The findings include:

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion, and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the Life Safety Code. These forces shall be applied at the latch stile.

The exit door from the basement boiler room was exercised at 1:52 p.m. on July 12, 2010. While the latch did release, the door did not swing open with at least 30 pounds of force being applied at the latch stile due to the binding of the door with the lower portion of the frame.

Based on observations made on July 12, 2010, the facility failed to assure that at least 1 foot-candle of light was available at the floor level in any exit corridor for purposes of illumination.

The findings include:

Illumination of means of egress, including corridors, shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values specified per section 7.8.2.1 of the Life Safety Code. The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge shall be illuminated to values of at least 1 foot-candle measured at the floor level per 7.8.1.3 of the Life Safety Code.

1. The corridor lights on the west wing were tested at 2:30 p.m. on July 12, 2010. When the overhead lights in the corridor were shut off the wall mounted lights intended to provide at least 1 foot-candle of illumination for egress purposes did not come on, possibly due to burned out bulbs.

2. The corridor lights on the east wing were tested at 2:41 p.m. on July 12, 2010. When the overhead lights in the corridor were shut off the wall mounted lights intended to provide at least 1 foot-candle of illumination for egress purposes did not come on, possibly due to burned out bulbs.

Based on observations made on July 12, 2010, the facility failed to assure that the battery-powered emergency light located in the room housing the generator was fully functional.

The findings include:

The Level 1 or Level 2 EPS equipment (being the emergency generator) location 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 battery-powered emergency light located in the generator room was tested at 1:57 p.m. on July 12, 2010. The light did not illuminate when the test button on the fixture was exercised.

Based on review of the fire drill reports at the facility on July 12, 2010, the facility failed to assure that the remote monitoring agency for its fire alarm system was automatically notifying the local fire department whenever a fire alarm was transmitted to it without prior knowledge or approval.

The findings include:

Emergency forces notification shall be provided to alert the municipal fire department of fire or other emergency per 9.6.4 of the Life Safety Code. The fire alarm system shall be arranged to transmit the alarm automatically per section 19.3.4.3.2 of the Life Safety Code via a remote or central station connection. The central station will immediately retransmit the alarm to the public fire service communications center and notify the subscriber of such action per sections 5-2.6.1.1 and 5-4.3.1 of NFPA 72, 1999 edition.

The fire drill reports were reviewed at the facility on July 12, 2010. The drills dated March 28, 2009 and March 30, 2009 both noted that the monitoring company had called the facility to verify if the fire department needed to be dispatched. Although these were drills, the monitoring company if not notified prior to the fire drill, must treat any alarm as a fire condition and automatically notify the fire department. The monitoring company may call the subscriber, in this case the facility, after the fire department has been notified to confirm if a fire exist or if the fire department may be cancelled. The facility must assure that its contract with the alarm monitoring company includes the automatic, and first, notification to the fire department.

Based on observations made on July 12, 2010, the facility failed to provide for sprinkler protection for a canopy exceeding 4 feet in width.

The findings include:

Sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 feet in width per section 5-13.8.1 of NFPA 13, 1999 edition.

The building is of Type V (111) construction and requires that it be protected by a complete automatic sprinkler system. Canopies over 4 feet in width in this type of construction are required to be protected by the sprinkler system. The canopy at the exit discharge from the basement laundry room stairway was measured at 5 feet 9 inches in width at 1:40 p.m. on July 12, 2010. There was no sprinkler protecting this canopy assembly. Note: No items of any nature, whether combustible or not, were stored or placed under this canopy at the time the observation was made.

Based on observations made on July 12, 2010, the facility failed to provide for electronic supervision of a control valve for the sprinkler system.

The findings include:

Where supervised automatic sprinkler systems are required, supervisory attachments shall be installed and electronically monitored for integrity in accordance with NFPA 72, 1999 edition per section 9.7.2.1 of the Life Safety Code. Monitoring shall include, but shall not be limited to, monitoring of control valves.

The kitchen range and hood are protected by the automatic fire sprinkler extinguishing system as observed at 3:00 p.m. on July 12, 2010. The shut-off valve for servicing the sprinklers was observed to have a chain and a padlock in place as the means for securing the valve against being shut-off by unauthorized persons. The shut-off valve was not electronically supervised to sound at least a local alarm or interconnected to the fire alarm control panel.

Based on review of the sprinkler service reports on July 12, 2010, the facility failed to assure that the fuel shut-off valve for the kitchen range was tested and maintained.

The findings include:

Upon activation of any fire-extinguishing system for a cooking operation, all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off per section 7-4.1 of NFPA 96, 1998 edition. All shut off devices shall require manual reset.

The kitchen range and hood are protected by the automatic fire sprinkler extinguishing system as observed at 2:58 p.m. on July 12, 2010. The sprinkler contractor reports dated September 5, 2007 and December 6, 2007, noted that the fuel shut-off interconnected to this sprinkler control had been tested at the time of those inspections. In reviewing the remainder of the sprinkler contractor and fire alarm reports since those dates noted above, there has been no mention or verification that the shut-off control had been tested and manually reset to assure its reliability in case of fire.

Based on observations made on July 12, 2010, the facility failed to assure that the self-closing mechanism on a linen chute door provided sufficient force to close and latch the door.

The findings include:

All chute loading doors into a linen chute shall be provided with a self-closing, positive-latching frame and gasketed fire door assembly approved for Class B openings and having a rating of not less than 1 hour per section 3-2.4.2 of NFPA 82, 1999 edition.

The fire rated linen chute door located in the basement soiled linen room was exercised at 2:04 p.m. on July 12, 2010. The self-closing mechanism on the door (spring loaded) did not exert sufficient force to close and latch the chute door.

Based on observations made on July 12, 2010, the facility failed to prevent items from being stored in an exit corridor unattended for periods exceeding 30 minutes.

The findings include:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18.

An exit corridor exists from the CT Scan and Procedure room suites with a set of traffic control doors near the Admission's desk. The set of traffic control doors did not have latching hardware. A wheeled assembly containing three hampers, a wheeled scale, a wheeled laundry cart frame and a portable X-Ray machine were observed to be parked in the exit corridor initially at 1:35 p.m. on July 12, 2010. The hampers were removed, but the other items were still in the exit corridor as observed at both 2:05 p.m. and 3:30 p.m. on July 12, 2010. Items can not be stored or left in the exit corridor if unattended for more than 30 minutes.

Based on observations made on July 12, 2010, the facility failed to provide documentation that all fabric curtains, valances and cubicle curtains were flame resistant in accordance with NFPA 701, 1999 edition.

The findings include:

1. A pink cubicle curtain was in use in the Mammography room as observed at 1:20 p.m. on July 12, 2010. The curtain did not have a tag on it attesting to its fire resistant properties or any documentation that it had been treated with a flame retardant made for fabric application.

2. Blue colored hanging curtains were hung on a wall in the Social Services office as observed at 2:35 p.m. on July 12, 2010. The curtains did not have tags on them attesting to their fire resistant properties or any documentation that they had been treated with a flame retardant made for fabric application.

3. Three window curtains were in use in the Special Care Unit (SCU) room as observed at 2:43 p.m. on July 12, 2010. The curtains did not have tags on them attesting to their fire resistant properties or any documentation that they had been treated with a flame retardant made for fabric application.

4. Valances were hung at the windows in the dining room as observed at 3:04 p.m. on July 12, 2010. The valances did not have tags on them attesting to their fire resistant properties or any documentation that they had been treated with a flame retardant made for fabric application.

Based on observations made on July 12, 2010, the facility failed to properly identify the locations served by each oxygen shut-off valve.

The findings include:

Shutoff valves for medical gases including oxygen shall be labeled to reflect the rooms that are controlled by such valves per section 4-3.5.4.2 of NFPA 99, 1999 edition.

1. The oxygen shut-off valve for the room now housing the CT Scan machine was examined at 1:30 p.m. on July 12, 2010. The listing on the shut-off valve showed that it for the "OR" instead of for the CT room. The CT room formerly was the OR and the listing on this shut-off valve must be updated to reflect the change of use or name of the room.

2. The oxygen shut-off valve located at the nurse's station was examined at 2:38 p.m. on July 12, 2010. There was no listing at this valve as to the room or rooms serviced by that valve.

Based on observations and review of fire alarm service reports made on July 12, 2010, the facility failed to provide documentation that the fusible link fire dampers had been tested every 4 years.

The findings include:

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, 1999 edition. Fusible links shall be replaced if they are found to be broken or damaged.

The two-hour fire wall between the Critical Access Hospital and the Meadowlark Assisted Living building was examined at 3:37 p.m. on July 12, 2010. Two ventilation ducts pass through this fire barrier above the men's restroom. It was confirmed that each of these ducts had a fusible link fire damper in them. There was no documentation that the fusible link assemblies had been tested on a 4-year rotation.

Based on observations made on July 12, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip.

A window air conditioner was plugged into a power strip in the Mammography room as observed at 1:20 p.m. on July 12, 2010.

Based on review of the fire policies and procedures of the facility on July 12, 2010, the facility failed to implement requirements for fire watches or evacuation whenever the fire sprinkler system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on July 12, 2010. The policies or procedures did not include safety measures to be taken when the fire sprinkler system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.7.6.1 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building.

Based on review of the fire policies and procedures of the facility on July 12, 2010, the facility failed to implement requirements for fire watches or evacuation whenever the fire alarm system was out of service.

The findings include:

The fire policies and procedures for the facility were reviewed on July 12, 2010. The policies or procedures did not include safety measures to be taken when the fire alarm system was out of service for more than 4 hours in any 24 hour period. The fire watch policy must incorporate the requirements stated in 9.6.1.8 of the Life Safety Code, which include notification of the authorities having jurisdiction (the State Agency at 406-444-4170 being one of those authorities that need to be notified and specifically stated in the policy) when the fire watch is initiated and ends, the documenting of the fire watch with a written record or log, or the evacuation of the building.