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Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation at 10:00 a.m. on 1/27/10 revealed the 1950 addition was a two story, protected, noncombustible, Type II(111) structure without a complete automatic sprinkler system. Review of previous survey data confirmed that condition.

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

Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. Two pairs of randomly observed corridor doors 1-SE-77A and 1-SE-77B would not positively latch into the frame. Findings include:

1. Observation at 4:00 p.m. on 1/26/10 revealed both pairs of corridor doors 1-SE-77A and 1-SE-77B to the Post Anesthesia Care Unit (PACU) suite would not latch into the frames. Interview with the director of special projects at the time of the observation revealed the top strike plates were not adjusted properly.

Based on observation, interview, and document review, the provider failed to maintain the one hour fire resistive rating of vertical openings in the northeast stair enclosure, dumbwaiter, and east stair enclosure. Findings include:

1. Observation at 9:30 a.m. on 1/27/10 revealed the door to the northeast stair enclosure on the fifth floor was a 1 3/4 inch metal door without a label indicating the fire resistive rating. That door appeared to be the original door that had been installed when the north wing was constructed in 1954. Document review of previous survey reports also identified that condition.

2. Observation at 10:30 a.m. on 1/27/10 revealed the doors to the dumbwaiter on all floors were not equipped with a label indicating the assemblies fire resistive rating. Interview with plant operations at that time revealed the dumbwaiter doors were the original doors when the building was constructed in 1927. Document review of previous survey reports also identified that condition.

3. Observation at 11:00 a.m. on 1/27/10 revealed the door separating the mechanical equipment room and the east stair enclosure was a 1-3/4 inch metal door without a label indicating the fire resistive rating. Document review of previous survey reports also identified that condition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. Storage room door 3-SE-16 and soiled linen room door 1-SE-39 would not latch into the frames. Findings include:

1. Observation at 4:30 p.m. on 1/26/10 revealed door 3-SE-16 would not latch into the frame. Observation at 4:45 p.m. on 1/26/10 revealed door 1-SE-39 would not latch into the frame when allowed to operate with the door closer. Interview with the director of special projects at the time of the observation revealed the doors required adjustment to allow the bolt to engage the strike plate. Further interview indicated that door had been operating properly during the last semi-annual safety check of the hospital.

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

1. Observation at 11:30 a.m. on 1/27/10 revealed the basement housekeeping room was only provided with one egress route that discharged onto the ground floor of the building. Further observation and review of previous survey data indicated that the provider 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 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 11:30 a.m. on 1/27/10 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 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 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 the west stair enclosure, northeast stair enclosure, and the northwest stair enclosure. Findings include:

1. Observation at 1:00 p.m. on 1/27/10 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 the restriction had existed since the stairs were constructed in 1973.

2. Observation at 1:30 p.m. on 1/27/10 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 2:00 p.m. on 1/27/10 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 2:30 p.m. on 1/27/10 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.

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

Based on observation and interview, the provider failed to install dual lamp battery pack emergency lighting for a transfer switch location. The fire pump transfer switch did not have dual lamp battery pack emergency lighting. Findings include:

1. Observation at 10:30 a.m. on 1/27/10 revealed the transfer switch for emergency power for the fire pump was not equipped with a dual lamp battery pack on an emergency circuit. Interview with the plant operations manager confirmed that finding.

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

1. Observation at 10:00 a.m. on 1/27/10 revealed the nurse responding to the simulated fire in Building 02 Pediatrics asked the security manager conducting the drill if it was a real drill. She expressed her desire to not be the one chosen to initiate the fire drill. After being told the drill was real she closed the door and asked the security manager if she needed to pull the alarm. He instructed her to do so, she went to the far end of the wing, pulled on the manual alarm box, and stated out loud "I pulled the alarm" although the alarm did not initiate. She was instructed to pull the alarm harder, the alarm activated, and the drill proceeded from that point without issues.

Interview with the security manager at the time of the observation confirmed that finding. He stated the wing the drill was held in had recently been remodeled, and the staff were new to the unit. He further stated the staff were probably not totally familiar with the location of all devices for the unit. He added the fire drills were held concurrently in all buildings and were held at least one drill per shift per three month quarter year (the minimum standard).

Based on observation and record review, the provider failed to install a complete automatic sprinkler system as required for the building construction type. Findings include:

1. Observation at 10:15 a.m. on 1/27/10 revealed the 1950 addition was a two story, protected, noncombustible, Type II(111) structure without a complete automatic sprinkler system. Document review of previous survey data confirmed a complete automatic sprinkler system had not been provided.

The facility meets the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to conduct the required inspection of the cooking facilitys fire extinguishing (ansul) system. Inspections of the ansul system for the range hood must be conducted not less then every six months. The two of two wet chemical ansul systems in the bakery and kitchen were tagged indicating the last inspection of that system was in April 2009. Findings include:

1. Observation at 3:00 p.m. on 1/27/10 revealed the wet chemical ansul system for the kitchen hood and the wet chemical ansul system for the bakery were tagged with an inspection tag dated April 2009. Interview with the administrator at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain stair enclosures between floors enclosed with construction having a fire-resistance rating of at least two hours. Findings include:

1. Observation at 10:45 on 1/27/10 revealed the 90 minute fire rated door to the north west stair enclosure on the first floor (NW5-7-1) would not latch into the frame. Interview with director of special projects at the time of the observation identified the panic hardware was loose not allowing the door to properly latch into the frame.