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Based on observation, record review, and staff interview as a result of the fire Life Safety Survey performed on July 5 and 6, 2011, it was determined that the Critical Access Hospital (CAH) failed to maintain the physical plant in a manner that provided a safe and functional environment for the patients, public, and staff. The Condition of Participation for the Physical Environment was not met as evidenced by the following findings:

1. Failed to meet the requirements in NFPA 99 (1999 edition) (Health Care Facilities Code).

2. Failure to have in place preventive maintenance programs to ensure that the Medical Gas Systems were in a safe operating condition and met all Code requirements. Refer to C 231, and the Fire Life Survey performed on July 5 and 6, 2011 under K76, K77, K78 and K140 for explanation of all deficiencies.

3. Failure to have in place preventive maintenance programs to ensure that the Vacuum System was in a safe operating condition and met all Code requirements. Refer to C 231 and the Fire Life Safety Survey performed on July 5 and 6, 2011 under K78 and K140 for explanation of all deficiencies.

Based on the results of the Fire Life Safety survey performed on July 5 and 6, 2011, it was determined that the Critical Access Hospital (CAH) failed to maintain the physical plant in a manner that provided a safe and functional environment for the patients, public, and staff. Findings include:

- did not store empty oxygen cylinders separate from full cylinders in the Nitrous storeroom,
- the electrical switch placement was not at least five feet from the floor in the Nitrous store room,
- the Nitrous storeroom lacked sufficient ventilation, and oxygen cylinders were not properly secured,
- did not provide both the Oxygen and Nitrous Oxide systems with duplex final line pressure regulators,
- the Nitrous Oxide manifold is defective and has been modified so as not to be capable of operation as manufactured,
- did not install a master alarm panel and indicators to monitor the gas systems,
- did not install an emergency oxygen supply connection at the cryogenic oxygen supply,
- did not recognize the seriousness of the Annual Medical Gas report which identified several immediate concerns with the Med Gas and Vacuum systems. These concerns were not properly addressed on a timely basis possibly exposing patients/residents to hazardous conditions.
- did not recognize that the Emergency Treatment room is a critical care area, the Respiratory Therapy (RT) area is considered a noncritical care area, these two areas are on the same zone valve,
- did not ensure that all critical care areas of the hospital had area alarms for the medical gas system,
- did not ensure that all zone valves have a pressure gauge downstream to indicate pressure in the line,
- did not provide proper labeling for all gas control valves,
- did not ensure that all zone valves were not located behind normally open or closed doors, and
- did not install master alarm panels to supervise potential system failures.