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Based on observation, record review, and interview, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The Type II (111) building had missing gypsum board ceiling in the mechanical room that provided the required structural member protection. Findings include:

1. Observation at 2:00 p.m. on 1/5/10, revealed the building was a two story, noncombustible, Type II (111) structure with a complete automatic sprinkler system. Review of the previous survey report confirmed that finding. The mechanical room containing air handling unit #1 on the second floor, had a section of gypsum board approximately 1 foot wide by 10 feet long removed exposing the unprotected steel bar joist. Interview with the director of plant operations at the time of the observation confirmed the gypsum board had been removed. He stated that area had been removed by a plumbing contractor during the installation of pipe supports without the knowledge of facility maintenance.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the employee break room and the mechanical room of the fourth floor. Findings include:

1. Observation at 10:03 a.m. on 01/05/10 revealed the corridor door to the employee break room (4006) on the fourth floor was not provided with positive latching hardware. Interview with the facility engineer at the time of the observation confirmed that finding. He stated it appeared that door had not had latching hardware installed when remodeled.

2. Observation at 10:11 a.m. on 01/05/10 revealed the corridor door to the mechanical room (4022) of the fourth floor was not positively latching. That door had the strike plate on the jamb covered with paper, so it would not positively latch. Interview with the facility engineer at the time of the observation confirmed that finding. He stated it appeared that door had been tampered with by construction workers needing to access the roof.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The corridor door for soiled utility room 1021 was not equipped with a door-closer. Findings include:

1. Observation at 9:00 a.m. on 1/6/10 revealed the corridor door for soiled utility room 1021 was equipped with a fire resistive rating of 60 minutes. That door did not contain a self-closing device and was observed in the open position. Interview with the director of plant operations at the time if the observation confirmed those findings. He indicated he was aware of the requirement for a self-closing device for that door and was not sure how the door-closer was missed during construction.

Based on observation and record review, the provider failed to maintain clear door widths of at least 32 inches for fourteen doors of the home health office on the third floor of the 1964 building. Findings include:

1. Observation beginning at 9:45 a.m. on 1/5/10 revealed corridor door 3051 for the home health office, computer room 2091, and offices 2087, 2090, 2092, 2093, 2094, 2095, 2096, 2097, 2098, 2101, and 2102 were only 30 inch wide doors but did not provide a clear opening width of 32 inches. Also office door 2083 was a 32 inch wide door and did not provide a clear opening width of 32 inches. Interview with the maintenance supervisor at the time of the observation confirmed those findings.

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.

The provider must comply with the National Fire Protection Association (NFPA 13), Health Care Facilities section 5-6.6 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.

Based on observation, measurement, and interview, the provider failed to maintain at least 18 inches of unobstructed space under one randomly observed sprinkler deflector. The shower room in the east wing was observed to be obstructed. (See attached section 5-6.6, Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.) Findings include:

1. Observation at 9:52 a.m. on 01/05/10 revealed a sprinkler head in the intravenous storage area of the pharmacy was obstructed by cardboard boxes. Those boxes were less than 18 inches from the bottom of the sprinkler deflector. Those boxes would interrupt the proper discharge and operation of the sprinkler. Interview with the facility engineer at the time of the observation revealed he was not aware of the obstructed sprinkler.

Based on observation, record review, and interview, the provider failed to maintain a one hour fire resistive separation between the ambulatory surgical center and other tenants in the building. Findings include:

1. Observation at 1:45 p.m. on 1/06/10 revealed the lower level of the ambulatory surgical building had a business occupancy tenant in the west half of the lower level. There was not a one hour fire resistive separation between the two occupancies. Review of the previous survey report confirmed that finding. Interview with the facility engineer at the time of the observation confirmed that finding.

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.