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Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for three randomly observed doors (chapel, staff only room at the end of the 300 wing, and Dutch door in the surgical wing). Findings include:

1. Observation at 1:30 p.m. on 11/19/13 revealed the corridor door to the chapel was not provided with positive latching hardware. Interview with the maintenance supervisor at the time of the observation revealed the room was being changed from the old emergency room to a new chapel. He stated it appeared the door had never had latching hardware installed since the original construction.

2. Observation at 2:00 p.m. on 11/19/13 revealed the corridor door to the staff only room at the end of the 300 wing was held open with an unapproved device (rubber floor wedge). Interview with the maintenance supervisor at the time of the observation revealed the room was used for the doctors' on call room. He stated he was unaware the door had been held open with the rubber wedge and removed it during the survey.

3. Observation at 2:30 p.m. on 11/19/13 revealed a Dutch corridor door for the shower room in the surgical wing. The door did not have the appropriate positive latching hardware and astragal between the upper leaves and the bottom leaves. Interview with the maintenance staff person at the time of the observation confirmed that finding.

Based on observation, the provider failed to maintain a one hour fire resistive path of egress from the basement to the exterior of the building. The north stairway from the east meeting room in the basement discharged into the main level corridor system. Findings include:

1. Observation at 10:15 a.m. on 11/19/13 revealed the north stairway from the east meeting room in the basement discharged into the main level corridor system. A continuous one hour fire resistive path of egress was not provided to the exterior of the building. Interview with maintenance staff at the time of the observation revealed the stair enclosure became an interior stair when the clinic (building 02) had been added.

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 width of corridors (clear and unobstructed) that served exit access by keeping a wheelchair scale in the 100 wing corridor near the exit. The scale was kept in the corridor by staff for easy access. Findings include:

1. Observation beginning at 3:00 p.m. until 3:45 p.m. revealed a wheelchair scale in the 100 wing corridor approximately 25 feet from the exit. The wheelchair scale was set in place adjacent to a storage room and plugged into a duplex electrical receptacle in the corridor wall. It projected into the corridor and restricted the 8 foot corridor width by 42 inches.

Interview with the administrator at 5:00 p.m. confirmed that condition. He was not aware the scale could not be left in the corridor if the remaining clear width was at least 4 feet.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for three randomly observed doors (chapel, staff only room at the end of the 300 wing, and Dutch door in the surgical wing). Findings include:

1. Observation at 1:30 p.m. on 11/19/13 revealed the corridor door to the chapel was not provided with positive latching hardware. Interview with the maintenance supervisor at the time of the observation revealed the room was being changed from the old emergency room to a new chapel. He stated it appeared the door had never had latching hardware installed since the original construction.

2. Observation at 2:00 p.m. on 11/19/13 revealed the corridor door to the staff only room at the end of the 300 wing was held open with an unapproved device (rubber floor wedge). Interview with the maintenance supervisor at the time of the observation revealed the room was used for the doctors' on call room. He stated he was unaware the door had been held open with the rubber wedge and removed it during the survey.

3. Observation at 2:30 p.m. on 11/19/13 revealed a Dutch corridor door for the shower room in the surgical wing. The door did not have the appropriate positive latching hardware and astragal between the upper leaves and the bottom leaves. Interview with the maintenance staff person at the time of the observation confirmed that finding.

Based on observation, the provider failed to maintain a one hour fire resistive path of egress from the basement to the exterior of the building. The north stairway from the east meeting room in the basement discharged into the main level corridor system. Findings include:

1. Observation at 10:15 a.m. on 11/19/13 revealed the north stairway from the east meeting room in the basement discharged into the main level corridor system. A continuous one hour fire resistive path of egress was not provided to the exterior of the building. Interview with maintenance staff at the time of the observation revealed the stair enclosure became an interior stair when the clinic (building 02) had been added.

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 width of corridors (clear and unobstructed) that served exit access by keeping a wheelchair scale in the 100 wing corridor near the exit. The scale was kept in the corridor by staff for easy access. Findings include:

1. Observation beginning at 3:00 p.m. until 3:45 p.m. revealed a wheelchair scale in the 100 wing corridor approximately 25 feet from the exit. The wheelchair scale was set in place adjacent to a storage room and plugged into a duplex electrical receptacle in the corridor wall. It projected into the corridor and restricted the 8 foot corridor width by 42 inches.

Interview with the administrator at 5:00 p.m. confirmed that condition. He was not aware the scale could not be left in the corridor if the remaining clear width was at least 4 feet.

Based on observation, record review, and interview, the provider failed to ensure staff were familiar with fire drill procedures and failed to document staff participation and alarm signaling. Findings include:

1. Observation at 3:30 p.m. on 11/19/13 during the fire drill revealed staff who responded to the simulated fire with extinguishers were unsure how to check the door of the simulated fire location to see if it might be safe to enter.

2. Record review on 11/19/13 of the fire drill sheets for the period of time from October 2012 through October 2013 did not document the staff persons who participated in the fire drills.

3. Record review on 11/19/13 of the fire drill sheets revealed was no documentation on the form confirming an alarm signal had been transmitted to the monitoring agency upon completion of the fire drill.

4. Interview with the maintenance supervisor at 3:45 p.m. on 11/19/13 confirmed those findings. He affirmed he could not verify the status of employee participation in fire drills or the transmission of the fire alarm signal.

Based on observation and interview, the provider failed to replace the back-up batteries for the fire alarm panel after five years and failed to install a smoke detector in the room with the fire alarm panel. Findings include:

1. Observation at 10:30 a.m. on 11/19/13 revealed the back-up batteries for the main fire alarm panel in the basement conference room air handling room were dated 5/08 (May 2008). Interview with the maintenance supervisor at the time of the observation revealed the most recent annual fire alarm inspection had been conducted in February 2013. He had not changed the batteries prior to the due date.

2. Observation at 10:45 a.m. on 11/19/13 revealed there was not a smoke detector located in the room (air handling unit room in the basement conference room area) with the main fire alarm panel. The room was not equipped with automatic fire sprinkler protection. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the automatic sprinkler system in reliable operating condition. Random observations revealed the fire sprinkler main did not have a hard sign with the hydraulic design information and the spare sprinkler box did not have the special tool. Findings include:

1. Observation at 10:00 a.m. on 11/19/13 revealed the fire sprinkler main in the basement had decals with the hydraulic design information applied to the piping. There was no hard sign with the hydraulic information at the fire sprinkler main water line.

2. Observation at 10:05 a.m. on 11/19/13 revealed the spare sprinkler box mounted on the wall by the fire sprinkler main was missing the special sprinkler tool.

3. Interview with the maintenance supervisor at the time of the observations confirmed those findings.