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Based on observations and interview made on January 4, 2013, it has been determined that the facility did not maintain the fire resistive rating of wall assemblies.

Findings include:

The penthouse above Emergency Room was reviewed at 7:30 a.m. on January 4, 2013. A new outside door had been installed and there is exposed construction around the new door which was not fire resistive for wall assemblies.

Based on observations made on January 4, 2013, the facility failed to maintain a corridor door automatic closer to completely close and latch a door in the surgery center.

Findings include:

In accordance with NFPA 101 and Section 19.3.6.3.2, doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

A west corridor door into the surgery center would not close upon observation on January 4, 2013 at 9:14 a.m.

Based on observations made on January 4, 2013, the facility failed to assure that there was no impediment to closing, or opening fully, a corridor door.

The findings include:

In accordance with NFPA 101 and Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex Sectino A.19.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

The large conference room in the CAH was reviewed at 10:45 a.m. on January 4, 2013. There was a chock (wedge) under the corridor door as Christmas decorations were spread out over the tables and volunteers were removing decorations from all corridors and large rooms and placing them in the conference room as a staging area. The corridor door continued to be propped open until afternoon.

Based on observations made on January 3, 2013, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

The findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The electrical room which lies directly above the therapy pool was reviewed at 10:00 a.m. on January 3, 2013. The Nystrom fire door which separates the electrical room from the pool mechanical room directly below was left open. This fire door must be remain closed when not in use to maintain separation between floors.

2. The mechanical room for the therapy pool was reviewed at 10:25 a.m. on January 3, 2013. A vertical shaft in the northeast corner of the room was open to the level above, was not sprinkled and was not enclosed with construction having a fire resistance rating of at least one hour.

Based on observation and review of 2-hour wall and door schedules for the Critical Access Hospital, the facility failed to install remotely operated openers hardware on all doors at fire separations.

Findings include:

In accordance with NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, and Section 1-2.1, this standard shall not prohibit the development of new, modified, or improved devices that meet the intent of these requirements. It shall be the responsibility of the manufacturer to furnish the information necessary to update the requirements pertaining to such new and improved devices.

Further, in accordance with NFPA 80 and Section 1-3.4, preparation of fire door assemblies for locks, latches, hinges, remotely operated or remotely monitored hardware, concealed closers, glass lights, vision panels, louvers, and astragals, and the application of plant-ons and laminated overlays shall be performed in accordance with the manufacturer's inspection service procedure and under label service.

The set of 90 minute rated fire doors at Xray/Admitting were reviewed at 8:45 a.m. on January 3, 2013. There are holes cut into the door frame and door for auto-opening/closing hardware, which were never installed, thus negating the rating for the frame and door enclosure.

Based on observations made on January 3, 2013, the facility failed to provide for a hard surface path from an exit discharge to the public way.

The findings include:

There shall be provided a hard surface path from the exit discharge to the public way in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The west doorway from the north wing of the CAH was reviewed at 9:45 a.m. on January 3, 2013. A three foot by three foot cement pad had been installed at the exit, but there was no hard path surface which extended the rest of the way to a public way.

Based on observations made on January 3, 2013, 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. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

The main south entrance to the Critical Access Hospital (CAH) was examined at 9:14 a.m. on January 3, 2013. The canopy just outside and west of the entrance measures 12 feet by 21 feet and is of combustible construction. This area must be protected by the installed sprinkler system.

Based on review of the fire sprinkler service and inspection reports and on observations made on January 3, 2013, the facility failed to assure that there was no obstruction to the coverage pattern of a sprinkler where combustible items were stored.

The findings include:

In accordance with NFPA 101 and Section 19.3.5.5, newly introduced cubicle curtains in sprinklered areas shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. Further, in accordance with Annex Section A.19.3.5.5, for the proper operation of sprinkler systems, cubicle curtains and sprinkler locations need to be coordinated. Improperly designed systems might obstruct the sprinkler spray from reaching the fire or might shield the heat from the sprinkler. Many options are available to the designer including, but not limited to, hanging the cubicle curtains 18 in. (46 cm) below the sprinkler deflector; using 1/2-in. (1.3-cm) diagonal mesh or a 70 percent open weave top panel that extends 18 in. (46 cm) below the sprinkler deflector; or designing the system to have a horizontal and minimum vertical distance that meets the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. The test data that forms the basis of the NFPA 13 requirements is from fire tests with sprinkler discharge that penetrated a single privacy curtain.

Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below.

Rooms 203 and 205 in the CAH were inspected at 9:30 a.m. on January 3, 2013. Privacy curtains around the entrance to the room did not have 1/2 inch mesh at the top. Spray pattern coverage for the installed sprinklers in the room were affected by the incorrect curtains.

Based on review of the fire sprinkler service and inspection reports and on observations made on January 3 and 4, 2013, the facility failed to assure that the fire sprinkler system was inspected on a quarterly basis and failed to assure that there was no obstruction to the coverage pattern of a sprinkler where combustible items were stored.

The findings include:

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

The fire sprinkler service and inspection reports were reviewed at the facility at 7:00 a.m. on January 3, 2013. There was no indication that the backflow preventers for the sprinkler system had received an annual test.

Based on observations made on January 4, 2013, the facility did not ensure all window dressings were flame resistant in accordance with the standards of NFPA 701 or had been treated with a flame resistant product made for fabrics.

Findings included:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The curtain covering the corridor door window in the medical supply room off the south hall, which is east of the nurses station was reviewed for flame resistance at 10:00 a.m. on January 4, 2013. There was no documentation that the curtain had been treated with a product to become flame resistant.

Based on observations made on January 3, 2013, the facility failed to assure that oxygen cylinders were protected from falling over or being knocked down.

Findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b 27) of NFPA 99, 1999 Edition.

At 9:20 a.m. on January 3, 2013, the Surgery Center was reviewed. One E-size oxygen cylinder was not secured in this area.

Based on observations made on January 3, 2013, the facility failed to maintain the the piped in medical gas systems in accordance with Chapter 4 of NFPA 99, 1999 Edition.

Findings include:

In accordance with NFPA 99 and 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 . . . .

The shutoff locations for the medical gas systems (vacuum & oxygen) were reviewed on the north and south wings of the Critical Access Hospital (CAH) at 10:00 a.m. on January 3, 2013. The plastic covers contained penciled in identification marks which were unreadable. The room numbers identified at the shut off locations did not match current room numbers identified at the rooms. One the plastic covers the rooms were identified as 1-6, and the rooms were really 10-15.

Note: Maintenance staff had used a label maker to update the shutoff locations which was very readable, this was done by noon on January 4, 2013.

Based on observation, the facility did not ensure heliport was maintained in accordance with NFPA 418.

Findings include:

NFPA 418, the Standard for Heliports, 1995 Edition, is referenced within the Life Safety Code as a mandatory requirement under section 2.1.1 and shall be considered part of the requirements of the Life Safety Code. No smoking shall be permitted within 50 feet of the landing pad edge per section 2-5 of NFPA 418. No smoking signs shall be erected at access/egress points to the heliport.

On January 3, 2013 at 1:45 p.m., the heliport lacked a NO SMOKING sign within the required 50 foot area around the heliport.