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Based on observations made during a tour of the building on September 27, 2011, the surveyor determined that the facility failed to ensure that all self closing doors serving smoke barriers and hazardous areas were adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor 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.

1. At approximately 10:25 a.m., the rated cross corridor doors on the second level were examined. Specifically the two sets of doors between the main hospital and Kalispell Regional Medical Center Hospital (PN 27-0051)were examined. Both sets of doors would not automatically close to positive latching when the doors were released by the surveyor.

2. At approximately 12:40 p.m., the rated door to the boiler room when released by the surveyor would not close to positive latching.

Based on the surveyor's observations of September 27, 2011, the surveyor determined that not all hazardous areas doors were being maintained with self closing doors.

Findings include:

In accordance with NFPA 101and Section 7.2.1.8.1, a door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2. Further, NFPA 101 Section 7.2.1.8.2 states, in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

At the basement level, the surveyor inspected the boiler room at approximately 12:35 p.m. Upon approaching the entry door to the boiler room, it was observed that the separation of the boiler room was not maintained from the other basement spaces. The rated entry door to the boiler room was being held open by a piece of equipment which caused the separation between the boiler room and other spaces not to be maintained.

Based on observations and discussions with facility staff on September 28, 2011, it was determined the facility failed to fully maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 Edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72.

At a approximately 2:00 p.m. after the testing of the fire alarm system, the surveyor inquired about the operation of the fire alarm system which included the location of the circuit disconnect for the system.
The location of the "circuit disconnect" (breaker location in an electrical panel) could not be determined. This breaker once found shall have a red marking as well.

Based on an observation made on September 27, 2011, the facility failed to ensure that fire extinguishers were being properly maintained in accordance with NFPA 10.

Findings include:

In accordance with Section 4-3.2 (b) of NFPA 10 (1998 Edition), there shall be "no obstructions to access or visibility" of portable fire extinguishers.

At approximately 1:00 p.m., the surveyor examined a fire extinguisher on the wall in a storage area in the basement garage. The extinguisher was partially visible and not fully accessible due to the fact that four spare tires had been placed in front of the fire extinguisher on the concrete floor.

On September 27, 2011, the surveyor made a tour of both levels of the entire building. As a result of that tour and the record of a digital picture, it was determined that not all requirements of NFPA 99, 1999 Edition, were being followed in regard to the storage of oxygen and other gases.

Findings include:

In accordance with NFPA 99 and Section 8-3.1.11.1, storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2. As required by NFPA 99 and Section 4-3.1.1.2 (2), the storage of gases within the confines of a building must be separated from all other spaces by one hour construction.

At approximately 1:10 p.m. on the lower level (auto garage) of the building, the adjoining spaces to the auto parking spaces were inspected. In one location there were up to twenty "K" cylinders of gases which included nitrogen and nitrous oxide and what appeared to be at least twelve "E" cylinders of oxygen. Although the cylinders were secured, they were not separated from the adjoining spaces by at least 1 hour construction. Section 8-3.1.11.1 shall be considered when storing non flammable gases such as nitrogen, nitrous oxide, and oxygen.

Based on surveyor observations on September 27, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1 Utilities,
Utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric requires that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against over current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS.

At approximately 8:30 a.m. in the waiting room of the clinic, the spaces under the cabinet for the fish tank were examined. An extension cord was in use for electrical equipment being used for the fish tank.