Endless Mountains Health Systems

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of three floors. Findings include: 1. Observation on October 30, 2024, at 12:39 p.m., revealed the 1st floor, Pharmacy Storage Room door was held open by unapproved means. (rubber door stop). Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the door being held open.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of nine smoke compartments. Findings include: 1. Observation on October 30, 2024, at 11:55 a.m., Basement level, revealed the Central Kitchen, walk in freezer, had a sprinkler head that was displaced outside of the sprinkler escutcheon. Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the sprinkler head being displaced.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain monthly inspection for eighteen of sixty-three portable fire extinguishers, affecting the entire facility. Findings include: 1. Observation on October 30, 2024, between 11:30 a.m., and 12:45 p.m., revealed 18 portable fire extinguishers, in various areas throughout the facility, had pre-dated monthly inspections for November 2024, marked on the tag. Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the pre-dated inspections.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 50182 Based on document review and interview, it was determined the facility failed to maintain the emergency generator which serves the entire facility. Findings include: 1. Observation on October 30, 2024, between 10:30 a.m., and 11:30 a.m., revealed the facility could not provide documentation for monthly testing, 30 minute run under load, battery electrolyte specific gravity or conductance test and operate transfer switches, being conducted within the last 12 months. Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the lack of documentation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 50182 Based on observation and interview, it was determined the facility failed to maintain portable oxygen cylinder storage in one location, affecting one of nine smoke compartments. Findings include: 1. Observation on October 30, 2024, at 11:46 a.m., Basement level, revealed 2 freestanding portable oxygen cylinders being stored in the medical gas storage room. Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the oxygen cylinders were not secured from falling over.”