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Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for one randomly observed corridor door 5-N-08 01 (old morgue). Findings include:

1. Observation at 10:00 a.m. on 8/02/16 revealed that corridor door 5-N-08 (old morgue) was not equipped with positive latching hardware. The door could be latched with a dead bolt but required a key. Interview with the maintenance supervisor at the time of the observation revealed the room was presently used for training and was left open for student access. The door could remain in the present condition if system smoke detection was added to the room.

This deficiency had the potential to affect all occupants within the smoke compartment.

Based on observation and record review, the provider failed to ensure two conforming exits were provided from the basement level. Findings include:

1. Observation at 10:30 a.m. n 8/02/16 revealed the basement housekeeping room was only provided with one egress route. That route discharged onto the ground floor of the building. Further observation and review of previous survey data indicated the provider had installed a sprinkler in the basement area in front of the elevator and in the stairs leading to the main level. Heat detection was also replaced with smoke detection to add an additional level of safety for that condition.

The building meets the FSES. Please mark an "F" in the (X5) completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and record review, the provider failed to maintain a protected path of egress from the basement to the exterior of the building. Findings include:

1. Observation at 11:00 a.m. on 8/02/16 revealed the continuous path of escape protected from other parts of the building was not provided from the basement to the exterior of the building. The door from the basement housekeeping storage room discharged onto the ground floor. Further observation and record review indicated the provider had installed sprinklers in the basement area in front of the elevator and in the stairs leading to the main level. The heat detection was also replaced with smoke detection that gave that condition an additional level of fire safety.

The building meets the FSES. Please mark an "F" in the (X5) completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and record review, the provider failed to maintain conforming exit stairs in three of five stair enclosures (west stair enclosure, northeast stair enclosure, and the northwest stair enclosure). Findings include:

1. Observation at 11:15 a.m. on 8/02/13 revealed the doors entering the west stair enclosures and the northeast stair enclosure restricted the width of the landing to less than 22 inches. The clearance varied from 7 1/2 inches to 17 inches on several floors. Review of previous survey data revealed those restrictions had existed since the stairs were constructed in 1973.

2. Observation at 11:30 a.m. on 8/02/16 revealed three of the five stair enclosures only had handrails on one side of the stairs. Record review of previous survey data indicated the single handrails were provided when the stair enclosures were constructed in 1973.

3. Observation at 11:45 a.m. on 8/02/16 revealed the handrail/guardrail height in the northeast stair enclosure measured 29 inches in height. Record review of previous survey data identified the handrail/guardrail was the original rail when the stair enclosure was constructed in 1946.

4. Observation at 12:00 noon on 8/02/16 revealed the door width on the northwest stair enclosure was less than 29 inches. Record review of previous survey data identified that door width had existed since the stair enclosure was constructed in 1946.

5. The items identified in findings 1 through 4 above meet the FSES. Please mark an "F" in the (X5) completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and interview, the provider failed to ensure one randomly observed marked exit was readily accessible at all times (1-E-66). The doors had a magnetic lock installed at the top of the doors. Findings include:

1. Observation at 2:00 p.m. on 8/02/16 revealed the alternate swing exit doors (1-E-66) were equipped with magnetic locking hardware. Interview with the director of plant operations supervisor at the time of the observation confirmed that condition. He stated the magnetic locks were not provided with power to enable the locking function. He was unaware the mechanism needed to be removed if not in use.

The deficiency had the capability to affect 100% of the smoke compartment occupants.

Based on observation and interview, the provider failed to maintain the required latching points for ninety-minute fire-rated doors (1-SE-83B) in a horizontal exit. Findings include:

1. Observation at 8:55 a.m. on 8/02/16 revealed the alternate swing double-egress, ninety-minute fire-rated doors marked 1-SE-83B were wood doors with top point latching only. Wood doors must have two points of latching unless certified by an approved testing company to maintain a ninety-minute fire-rating on the label with only one point of latching. Interview with the director of plant operations at the time of the observation revealed there was no documentation providing such an endorsement.

The deficiency has the potential to affect all occupants of that smoke compartment.

Surveyor: 14180
2. Observation at 2:00 p.m. on 8/02/16 revealed the west leaf of the alternate swing double-egress, ninety-minute fire rated doors marked 1-SE-18 would not latch into the frame. Interview with the maintenance supervisor at the time of the observation indicated the doors were on a preventive maintenance schedule. Maintenance was notified, and a work order for the repair was initiated.

The deficiency had the potential to affect all occupants of that smoke compartment.

Based on observation and interview, the provider failed to ensure staff were familiar with the facility's fire drill policy and procedures. Findings include:

1. Observation of the fire drill beginning at 3:30 p.m. on 8/02/16 revealed staff in the smoke compartment went through the steps of responding to the discovery of the simulated fire without actually pulling the fire alarm. After being notified by the plant operations manager to actually pull the nearest manual fire alarm station, the fire alarm was sounded, and the drill response began. The door to patient room 306 had been left open. Further observation revealed plant operations personnel responded to the simulated fire with fire extinguishers. Interview with the plant operations manager at the time of the observation revealed the plant operations personnel were part of the Fire Brigade who were the main responders to the fire alarm prior to the arrival of the local fire department.

2. Document review beginning at 8:00 a.m. on 8/03/16 revealed the following:
*An annual Fire Brigade training test form was part of the fire drill policy information. The form was not dated and had contact information referring to two supervisory personnel who had not been employed by the provider for approximately two years. Interview with the plant operations manager at the time of the document review revealed the Annual Fire Brigade training had not been held for approximately two years and that there was not an updated test form available. There was no documentation showing the fire drill participation levels by the Fire Brigade.
*There was no documentation regarding the level of fire drill training (employees who were present and participated) achieved by the implementation of the fire drills. The intent of the fire drill training is to have each employee participate quarterly (four times per year). The provider has approximately 700 employees in the main building complex without documentation of that participation.

Based on observation and interview, the provider failed to ensure the fire alarm system provided effective warning to all parts of the building in two randomly observed locations (first floor north elevator lobby and the sleep lab egress corridor). Findings include:

1. Observation at 3:30 p.m. on 8/2/16 during a fire drill revealed missing fire alarm and signaling notification appliances in two randomly observed areas. While walking through portions of the facility when the fire alarm was active for the combination signaling/strobe notification appliance observation revealed that was not provided in the egress corridor in the sleep lab area. That same issue was also found in the first floor north elevator lobby. The missing notification appliances had the potential to not properly warn occupants of the fire location or other notification of potential hazard.

Interview with the director of plant operations at the time of the above observation confirmed that condition. He indicated he was unaware those notification appliances were missing and was unsure why they had not been installed.

Based on observation and interview, the provider failed to install a smoke detector in the proper location in the dialysis water room. Findings include:

1. Observation at 1:30 p.m. on 8/02/16 revealed the smoke detector installed in the dialysis water room was mounted approximately four feet below the concrete ceiling. Interview with the director of plant operations at the time of the observation revealed the room previously had a lay-in ceiling that was at the same height of the smoke detector.

The deficiency affected one of numerous requirements for the installation and operation of the fire alarm system.

Based on record review and interview, the provider failed to verify the maintenance of the sprinkler system had been performed. Findings include:

1. Review of the provider's sprinkler maintenance records on 8/03/16 revealed a 5-year Report of Inspection & Testing of Water Based Fire Protection System dated December 30, 2014 for the East System/MRI Preaction (the first 5-year inspection). Items noted by the inspection company included:
*Summary: The Dry Preaction Piping has lots of scale.
*Explanation on "No" answers: The Supply side main control valve did not completely shut water flow off.
*Desired Improvements: Replace the 6" OS&Y (Supply side of BFP [Building Fire Pump]); Replace Preaction piping that has excessive scale.

Interview at 8:30 a.m. on 8/03/16 with the plant operations manager revealed there was no documentation the noted items had been corrected.

2. Review of the provider's sprinkler maintenance records on 8/03/16 revealed a 5-year Report of Inspection & Testing of Water Based Fire Protection System dated January 2, 2015 for the SE Addition/Main Bldg (the first 5-year inspection). Items noted by the inspection company included:
*Summary of internal inspection: There was a bad aux [auxiliary] drain valve in oxygen. System appears in good condition storage room, south main floor, ball drip on fire pump test header line. There is extreme corrosion on [the] 2" pipe - 2 south.
*Desired Improvements: Replace bad ball drip/aux drain valve.

Interview at 8:30 a.m. on 8/03/16 with the plant operations manager revealed there was no documentation the noted items had been had been corrected.

Based on observation and interview, the provider failed to maintain a continuous unobstructed path of egress to two of three exits from the third floor. Findings include:

1. Observation at 1:30 p.m. on 8/02/16 revealed the both entrances to the intensive care unit (ICU) on the third floor were controlled with a magnetic lock with a card reader entry. Both of the exit stairs were located within the ICU suite. The third exit was a horizontal exit controlled by a delayed egress lock. Interview with the maintenance supervisor at the time of the observation confirmed the exit stairs would not be accessible to anyone without the proper badge. Because the ICU suite only needed controlled access into the suite and not exiting the suite delayed egress locks would eliminate the issue.

The deficiency had the potential to affect all patients, staff, and general public present on the third floor.

A. Based on observation, testing, and interview, the provider failed to:
*Ensure hazardous areas were properly protected in two randomly observed locations (Therapy Center storage/supply room and Therapy Center soiled linen holding room).
*Ensure emergency exit egress lighting was checked on a regular basis for functionality (Dakota Medical Square).
*Ensure emergency exit egress lighting was functioning properly (Waiting area of Suite E201 in Physicians Plaza).
*Ensure the electrical system was maintained in one randomly observed location (Suite E105 Physicians Plaza). The electrical panels were not provided with proper circuit panel directories.
Findings include:

1. Observation at 9:30 a.m. on 8/2/16 in the Therapy Center revealed a storage/supply room off the north corridor. The door to the room had a 45 minute fire rating and the room was designed as a one hour fire ted construction. Upon testing the door for self-closing capabilities it was found the door was not provided with a door closer. A door closer should have been provided on that fire rated door. This condition was also found on the soiled linen holding room in that same corridor.

Interview with the environmental services manager confirmed that condition. He indicated he was not aware those doors required a door closer.

2. Observation at 2:35 p.m. on 8/2/16 in Dakota Medical Square revealed emergency lighting was provided with a variety of different types of lighting fixtures with battery power as the backup power source. Interview with the environmental services director when questioned on how the ballast type fixtures were tested on a monthly basis indicated he was unaware how the emergency lighting was tested. He then placed a call to plant operations to see how the ballast lighting was tested. Plant operations indicated the ballast lighting was hard to test and did not indicate if they were tested on a monthly basis. Interview with a staff member that works in the facility when questioned if lighting was available when normal power is lost revealed she was unaware if proper lighting was available and indicated that the hallways gets very dark.

Interview with the plant operations manager during the exit interview confirmed the above issue. He indicated the ballast lighting fixtures were hard to test and did not confirm if these lights had been tested on a monthly basis or when they were last tested.

3. Observation at 8:25 a.m. on 8/3/16 in Suite E201 of Physicians Plaza revealed emergency lighting in the waiting room area was provided with a combination exit sign/dual bulb light fixture with a battery pack backup power source. Testing of that light by pressing the fixture test button revealed that light was not functioning under battery power. That fixture should be capable of provided a minimum of ninety minutes of emergency lighting upon loss of normal power.

Interview with the environmental services director at the time of the above observation confirmed that condition. He indicated he was unaware that emergency light fixture was not working properly. He was aware of the requirement of how long emergency lighting is supposed to be available. He also indicated the battery pack emergency lights are checked on a monthly basis for thirty seconds by maintenance personnel.

4. Observation at 9:35 a.m. on 8/3/16 in Suite E105 of Physicians Plaza revealed three electrical panels in back exit egress hallway. Opening of the electrical panel cover revealed no circuit directory was available. The designated circuit panel directory located on the panel door should have been provided to reflect the power supply for each circuit.
Interview with the environmental services manager at the time of the above observation confirmed that condition. He indicated he was aware those electrical panels should be provided with circuit directories and was unsure why they were not.

B. Based on observation and interview, the provider failed to install a remote stop button for two of two generators located in the physical plant building. Findings include:

1. Observation at 9:00 a.m. on 8/02/16 revealed there were not emergency stop buttons installed outside of the room containing two diesel powered generators. Interview with the maintenance supervisor at the time of the observation revealed he was unaware of the remote stop requirement for the generators.

"All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover or located elsewhere on the premises where the prime mover is located outside the building." (National Fire Protection Association 110, Chapter 3-5.5.6, 1999 Edition).

Based on observation and interview, the provider failed to maintain the requirements for the liquid oxygen transferring room. Findings include:

1. Observation at 9:15 a.m. on 8/03/16 revealed the liquid oxygen transfilling room had a one-hour fire-rated corridor door (G-S-77). Testing of the door at the time of the observation revealed the door would not close and latch with the operation of the closer. Interview with the director of plant operations confirmed that finding.

The deficiency affected one of several requirements for liquid oxygen transfilling and storage.