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Based on observation and document review, the provider failed to meet the minimum construction standards of health care occupancies. Findings include:

1. Observation at 4:00 p.m. on 7/22/13 revealed the building was a single story, slab on grade building, constructed of heavy timber, Type IV (2HH) in the patient wings and protected noncombustible, Type II (111) in the core area. The core of the building had a partial basement. The building did not have a complete automatic sprinkler system. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet 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 maintain corridor separation from use areas by walls with at least a 30 minute fire resistance rating in the corridor adjacent to the construction area. A combustible (wood) construction barrier was installed in the corridor. Findings include:

1. Observation at 4:15 p.m. on 7/22/13 revealed a combustible, oriented-strand board (OSB) wood barrier installed in the corridor from the nurses' station past the boiler room to building 02 (the Wellness Center). The OSB barrier terminated under the lay-in ceiling in the corridor. Inspection above the lay-in ceiling revealed an opening through the wall into the construction area approximately 20 feet wide floor to roof deck. There was no separation above the lay-in ceiling from the construction area. Interview with the facilities manager at the time of the observation revealed he expected the architect and contractors to know the requirements for separation from a functioning health care facility.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas for the boiler room. Several openings around pipe penetrations of the corridor wall above the lay-in ceiling from the boiler room were not sealed with an appropriate firestop material. Findings include:

1. Observation at 10:15 a.m. on 7/23/13 revealed openings around two penetrations of the corridor wall from the boiler room. A 3/4 inch diameter electrical conduit and control wiring penetration openings above the lay-in ceiling through the block wall were not firestopped with an approved material. Interview with the facilities manager at the time of observation confirmed those findings. He revealed those penetrations were made by contractors over the past several months with the new construction.

Based on observation and review of previous survey documents, the provider failed to maintain two acceptable exits from the basement level of the building. Findings include:

1. Observation at 4:00 p.m. on 7/22/13 revealed the basement level of the facility did not have conforming exits. Both interior stairs from the basement discharged into the corridor on the first floor level. There was not a one hour fire rated exit passageway to the exterior of the building. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet 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 maintain exit access so exits were readily accessible at all times. The south patient wing exit through the construction area was not usable due to concrete work, lack of lighting, and lack of a ramp. Findings include:

1. Observation at 4:30 p.m. on 7/22/13 revealed the south patient wing exit through the construction area was not usable. There was a 2 foot wide gap between the floor and the block outer wall in the construction area that was 2 feet deep. A 1/2 inch thick piece of plywood was extended across the opening. There was not a ramp or other acceptable means to use the exit in an emergency. There was no lighting provided for the exit discharge from the patient wing. Interview with the facilities manager at the time of the observation confirmed that finding and discussed the need to have the exit usable at all times. He revealed the contractors had removed the ramp that had been in place previously in order to perform concrete and block work at the exit location. He stated a ramp would be installed immediately to make the exit discharge usable.

Based on observation and record review, the provider failed to maintain clear door widths of at least 32 inches for ten randomly observed sets of exit access doors. Findings include:

1. Observation from 8:00 a.m. until 11:00 a.m. on 7/23/13 revealed the following doors/leaves were only 30 inches wide and provided less than 32 inches of clear open width:
*The double-doors (each leaf) for the main entrance/exit.
*The double-doors (each leaf) for the entrance vestibule.
*The corridor double-doors (each leaf) from the lobby to the vestibule.
*The doctors' locker room corridor door.
*The south door to the scope room in the north patient wing.
*The nurses' locker room corridor door in the south patient wing west.
*The doctors' changing room (adjacent to surgery) door in the east-west corridor.
*The nurses' changing room door.
*The double-doors (each leaf) to the corridor on the south side of the kitchen.
*The central sterilizing room corridor double-doors (each leaf).

Review of previous survey records at the time of the above observations confirmed the above findings.

The building will meet 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 install emergency lighting of at least 90 minute duration. Emergency lighting was not provided at two locations (southwest stair and medical records storage room) in the basement of the facility. Findings include:

1. Observation beginning at 8:30 a.m. on 7/23/13 revealed emergency lighting was not installed at the southwest stair area or in the medical records storage room located in the basement of the facility. Interview with the facilities manager at the time of the observations revealed neither battery nor generator operated emergency lights were located in those areas.

Based on record review and interview, the provider failed to conduct and correctly document monthly drills for the twelve month period beginning July 2012. Findings include:

1. Fire drill record review revealed no documentation indicating information regarding the following items:
*Reception of the transmitted fire alarm signal by the monitoring agency.
*The time the fire drills occurred.
*Whether or not the fire alarm was sounded.
*Whether or not each employee (doctors and EMTs exempted) had participated in a fire drill not less than once in each three-month period (quarter of the year).

No fire drill documentation was available for July and October 2012 and February 2013. One drill was documented after 7:00 p.m. on 12/14/12 (9:00 p.m) that included the second shift personnel.

Interview with the facilities manager at 1:15 p.m. on 7/23/13 revealed the provider had two personnel shifts (7:00 a.m. to 7:30 p.m. and 7:00 p.m. to 7:30 a.m.) for the health care facility. Further interview with the facilities manager at 1:30 p.m. on 7/23/13 confirmed those findings.

Based on observation and document review, the provider failed to meet the minimum construction standards of health care occupancies. Findings include:

1. Observation at 4:00 p.m. on 7/22/13 revealed the building was a single story, slab on grade building, constructed of heavy timber, Type IV (2HH), in the patient wings and protected noncombustible Type II (111) in the core area. The core of the building had a partial basement. The building did not have a complete automatic sprinkler system. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet 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 record review and interview, the provider failed to ensure the installed automatic sprinkler system was inspected annually. Record review of previous fire sprinkler system inspections revealed documentation for inspection of the automatic sprinkler system was not available since 5/18/09. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at revealed a fire sprinkler inspection report was not available since 5/18/09. Interview with the facilities manager at 1:00 p.m. on 7/23/13 revealed the sprinkler piping for the basement (combustible storage location) had been installed in 2008.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in mechanical room 216. The provider must comply with the National Fire Protection Association (NFPA 70), National Electrical Code (NEC) article 110.26(A)(1) Depth of Working Space (see attachment). Findings include:

1. Observation at 4:15 p.m. on 7/22/13 revealed electrical panels in the mechanical room 216 were obstructed by equipment floor dollies, a bag of Jolly Gardener top soil, a five gallon bucket of Shell heavy duty engine oil, and other miscellaneous items. There was not a minimum three feet of clear working space provided although the space was marked. Interview with the facilities manager at the time of the observation confirmed that finding. The floor dollies and other items were relocated during the survey.