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Based on observation and document review, the provider failed to ensure all vertical openings between one of four floors were enclosed with construction having a fire-resistance rating of at least one hour; a vertical opening between the 3rd and 4th floor was not protected. Findings include:

1. Observation at 10:30 a.m. on 9/24/13 revealed a ventilation shaft in the utility closet of the 4th floor rehabilitation activity room. That ventilation shaft was being used by the 3rd floor pediatric negative pressure room that exhausted air to the roof above the 4th floor. That shaft should have been enclosed in a one hour fire resistant construction between all floors. Interview with the plant operation manager at the time of the observation revealed that ventilation shaft had been installed approximately two years ago from the date of this survey. He was unaware that shaft required fire rated protection.

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

1. Observation at 11:45 a.m. on 9/24/13 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 10:00 a.m. on 9/24/13 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 manager 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.

The building meets the FSES. Please mark an "F" in the (X5) 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 for one randomly observed area (laundry room corridor door G-N-01). That door was not self-closing and not smoke resistant. Findings include:

1. Observation at 10:55 a.m. on 9/25/13 revealed a laundry room over 100 square feet. That room would be considered a hazardous room and required sprinkler protection, a self-closing door, and smoke resisting partitions/doors. Door G-N-01 to that room was provided with a self-closing device. That self-closing device did not close and latch the door.That door was equipped with a transfer grill that would not resist the passage of smoke. Interview with the plant operations manager at the time of the observations confirmed those findings.

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 on 9/25/13 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 interview, the provider failed to maintain three of three stair enclosures in the south wing with a fire-resistance rating of at least one hour due to openings around sprinkler pipe penetrations (north, west, and south stair enclosures) were not sealed. Findings include:

1. Random observation throughout the day on 9/24/13 revealed unsealed openings around sprinkler pipe penetrations into the required one hour rated exit stair enclosures. Those areas observed: above door 2-S-12 of the west stair enclosure, above door SWS-2-4 of the south stair enclosure, and on the 4th floor of the north stair enclosure. Interview with the plant operations manager at the time of those observations confirmed those findings.

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 10:25 a.m. on 9/25/13 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 1:00 p.m. on 9/24/13 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 1:30 p.m. on 9/24/13 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 9/24/13 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 9/24/13 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, testing, and interview, the provider failed to ensure the means of egress components were maintained for two randomly observed doors into enclosed stairway towers (2-S-17 and SWS-1-4). Those doors would not close and latch into their frame. Findings include:

1. Observation at 8:55 a.m. on 9/24/13 revealed a ninety minute fire rated door (2-S-17) into the
west exit stair enclosure. That door would bind against the frame and was not able to close and latch into the door frame under power of the self-closing device.

2. Observation at 10:45 a.m. on 9/24/13 revealed a ninety minute fire rated door (SWS-1-4) into the south exit stair enclosure. That door would bind against the frame and was not able to close and latch into the door frame under power of the self-closing device.

3. Interview with the plant operations manager at the time of those observations confirmed those conditions.

Based on observation, interview, and testing, the provider failed to ensure exits were readily accessible at all times. Two randomly observed marked exit doors (both fourth floor exit doors into exit stair towers) were equipped with magnetic locks. The doors were not equipped with signage that indicated how to open the magnetically locked doors in an emergency. Findings include:

1. Observation beginning at 1:15 p.m. on 9/24/13 revealed two observed marked exit doors from the fourth floor were equipped with magnetic locks. There was no signage indicating how to open the magnetically locked doors in an emergency.

2. Interview with the plant operations manager at the time of observatin confirmed that condition. He revealed the doors were delayed egress doors and could be opened even if locked.

3. Testing the doors at the time of the observation confirmed they were delayed egress. Further interview with the safety officer revealed that signage had not been provided due to the needed increased security on that labor and delivery floor. The provider was advised that a thirty second delayed egress would be allowed at those doors due to the security issue.

Based on observation and interview, the provider failed to furnish one randomly observed exit sign (above corridor door I-E-104) to ensure the path of egress to an exit was identified. Findings include:

1. Observation at 10:45 a.m. on 9/25/13 revealed a set of cross-corridor doors I-E-104 that were held open with magnetic hold open device. When closed those doors blocked the view of exit signage at the ends of the corridor. Exit signage shall be provided above those doors to indicate the path of egress when those doors were closed. Interview with the plant operations manager at the time of observation confirmed that condition.

Based on observation and interview, the provider failed to correctly install two randomly observed exit signs (east 3rd floor corridor and west 3rd floor corridor) to ensure the path of egress to exits were identified. Findings include:

1. Observation at 2:45 p.m. on 9/24/13 revealed two exit signs on the 3rd floor that had been installed incorrectly. Those signs should have been rotated, so they would have been visible to occupants on either side of the corridor smoke compartment doors. Interview with the plant operations manager and safety officer at the time of the observation confirmed those findings. They stated those signs had probably been installed incorrectly when the 3rd floor renovation had been done.

Based on observation and interview, the provider failed to maintain the automatic sprinkler system in reliable operating condition. The provider must comply with the National Fire Protection Association (NFPA-13) Standard for the Installation of Sprinkler Systems section 18, System Inspection, Testing, and Maintenance. Random observation of sprinklers in the bakery and kitchen freezer revealed three sprinklers with dust build-up and corrosion on them. Findings include:

1. Observation at 9:10 a.m. on 9/25/13 revealed one quick-response sprinkler in the walk-in kitchen freezer with corrosion build-up and two quick-response sprinklers in the bakery with dust build-up. Those conditions could affect the reliability of operation of those sprinklers. Interview with the plant operations manager at the time of the observations confirmed those conditions.

Based on observation and interview, the provider failed to install the stove under the kitchen range exhaust hood in accordance with NFPA 96. The hood canopy must extend a horizontal distance of not less than six inches beyond the edge of the cooking surface on all open sides. Findings include:

1. Observation at 9:45 a.m. on 9/25/13 revealed a stove that extended beyond the edges of the overhead range hood in the bakery. Interview with the plant operations manager and bakery staff at the time of the observation revealed the stove could be moved under the hood without any issues.

Based on observation and document review, the provider failed to maintain one randomly observed stair enclosure between floors enclosed with construction having a fire-resistance rating of at least one hour. Openings around sprinkler pipe penetrations of the NWS-6-4 stair enclosure were not sealed. Findings include:

1. Observation at 11:15 a.m. on 9/24/13 revealed unsealed openings around sprinkler pipe penetrations of the NWS-6-4 stair enclosure. Interview with the plant operations manager at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to provide proper signage at one of one location (powered horizontal sliding exit doors from the emergency department). Findings include:

1. Observation at 10:05 a.m. on 9/25/13 revealed horizontal sliding exit doors from the emergency department. Those doors were operated by power upon approach of a person. In the event of power failure, those doors should have been provided with readily visible signage that read "IN EMERGENCY, PUSH TO OPEN." Those doors were not provided with the required signage. Interview with the plant operation manager at the time of observation confirmed that condition.

Based on observation and document review, the provider failed to ensure all vertical openings between one of four floors were enclosed with construction having a fire-resistance rating of at least one hour; a vertical opening between the 3rd and 4th floor was not protected. Findings include:

1. Observation at 10:30 a.m. on 9/24/13 revealed a ventilation shaft in the utility closet of the 4th floor rehabilitation activity room. That ventilation shaft was being used by the 3rd floor pediatric negative pressure room that exhausted air to the roof above the 4th floor. That shaft should have been enclosed in a one hour fire resistant construction between all floors. Interview with the plant operation manager at the time of the observation revealed that ventilation shaft had been installed approximately two years ago from the date of this survey. He was unaware that shaft required fire rated protection.

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

1. Observation at 11:45 a.m. on 9/24/13 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 10:00 a.m. on 9/24/13 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 manager 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.

The building meets the FSES. Please mark an "F" in the (X5) 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 for one randomly observed area (laundry room corridor door G-N-01). That door was not self-closing and not smoke resistant. Findings include:

1. Observation at 10:55 a.m. on 9/25/13 revealed a laundry room over 100 square feet. That room would be considered a hazardous room and required sprinkler protection, a self-closing door, and smoke resisting partitions/doors. Door G-N-01 to that room was provided with a self-closing device. That self-closing device did not close and latch the door.That door was equipped with a transfer grill that would not resist the passage of smoke. Interview with the plant operations manager at the time of the observations confirmed those findings.

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 on 9/25/13 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 interview, the provider failed to maintain three of three stair enclosures in the south wing with a fire-resistance rating of at least one hour due to openings around sprinkler pipe penetrations (north, west, and south stair enclosures) were not sealed. Findings include:

1. Random observation throughout the day on 9/24/13 revealed unsealed openings around sprinkler pipe penetrations into the required one hour rated exit stair enclosures. Those areas observed: above door 2-S-12 of the west stair enclosure, above door SWS-2-4 of the south stair enclosure, and on the 4th floor of the north stair enclosure. Interview with the plant operations manager at the time of those observations confirmed those findings.

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 10:25 a.m. on 9/25/13 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 1:00 p.m. on 9/24/13 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 1:30 p.m. on 9/24/13 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 9/24/13 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 9/24/13 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, testing, and interview, the provider failed to ensure the means of egress components were maintained for two randomly observed doors into enclosed stairway towers (2-S-17 and SWS-1-4). Those doors would not close and latch into their frame. Findings include:

1. Observation at 8:55 a.m. on 9/24/13 revealed a ninety minute fire rated door (2-S-17) into the
west exit stair enclosure. That door would bind against the frame and was not able to close and latch into the door frame under power of the self-closing device.

2. Observation at 10:45 a.m. on 9/24/13 revealed a ninety minute fire rated door (SWS-1-4) into the south exit stair enclosure. That door would bind against the frame and was not able to close and latch into the door frame under power of the self-closing device.

3. Interview with the plant operations manager at the time of those observations confirmed those conditions.

Based on observation, interview, and testing, the provider failed to ensure exits were readily accessible at all times. Two randomly observed marked exit doors (both fourth floor exit doors into exit stair towers) were equipped with magnetic locks. The doors were not equipped with signage that indicated how to open the magnetically locked doors in an emergency. Findings include:

1. Observation beginning at 1:15 p.m. on 9/24/13 revealed two observed marked exit doors from the fourth floor were equipped with magnetic locks. There was no signage indicating how to open the magnetically locked doors in an emergency.

2. Interview with the plant operations manager at the time of observatin confirmed that condition. He revealed the doors were delayed egress doors and could be opened even if locked.

3. Testing the doors at the time of the observation confirmed they were delayed egress. Further interview with the safety officer revealed that signage had not been provided due to the needed increased security on that labor and delivery floor. The provider was advised that a thirty second delayed egress would be allowed at those doors due to the security issue.

Based on observation and interview, the provider failed to furnish one randomly observed exit sign (above corridor door I-E-104) to ensure the path of egress to an exit was identified. Findings include:

1. Observation at 10:45 a.m. on 9/25/13 revealed a set of cross-corridor doors I-E-104 that were held open with magnetic hold open device. When closed those doors blocked the view of exit signage at the ends of the corridor. Exit signage shall be provided above those doors to indicate the path of egress when those doors were closed. Interview with the plant operations manager at the time of observation confirmed that condition.

Based on observation and interview, the provider failed to correctly install two randomly observed exit signs (east 3rd floor corridor and west 3rd floor corridor) to ensure the path of egress to exits were identified. Findings include:

1. Observation at 2:45 p.m. on 9/24/13 revealed two exit signs on the 3rd floor that had been installed incorrectly. Those signs should have been rotated, so they would have been visible to occupants on either side of the corridor smoke compartment doors. Interview with the plant operations manager and safety officer at the time of the observation confirmed those findings. They stated those signs had probably been installed incorrectly when the 3rd floor renovation had been done.

Based on record review and interview, the provider failed to ensure the automatic fire alarm system was maintained in accordance with NFPA 70 and NFPA 72. The annual fire alarm test and inspection was not being performed and records of maintenance were not available. Findings include:

1. Review of the provider's records at 2:30 p.m. on 9/25/13 revealed the fire alarm system had not been tested or inspected in accordance with an approved maintenance program. Interview with the director of plant operations at the time of the review confirmed that finding. He further revealed he had believed the smart system utilized by the fire alarm system had been adequate maintenance, and the annual fire alarm inspection would not be necessary.

Based on observation and interview, the provider failed to maintain the automatic sprinkler system in reliable operating condition. The provider must comply with the National Fire Protection Association (NFPA-13) Standard for the Installation of Sprinkler Systems section 18, System Inspection, Testing, and Maintenance. Random observation of sprinklers in the bakery and kitchen freezer revealed three sprinklers with dust build-up and corrosion on them. Findings include:

1. Observation at 9:10 a.m. on 9/25/13 revealed one quick-response sprinkler in the walk-in kitchen freezer with corrosion build-up and two quick-response sprinklers in the bakery with dust build-up. Those conditions could affect the reliability of operation of those sprinklers. Interview with the plant operations manager at the time of the observations confirmed those conditions.

Based on observation and interview, the provider failed to install the stove under the kitchen range exhaust hood in accordance with NFPA 96. The hood canopy must extend a horizontal distance of not less than six inches beyond the edge of the cooking surface on all open sides. Findings include:

1. Observation at 9:45 a.m. on 9/25/13 revealed a stove that extended beyond the edges of the overhead range hood in the bakery. Interview with the plant operations manager and bakery staff at the time of the observation revealed the stove could be moved under the hood without any issues.

Based on observation and document review, the provider failed to maintain one randomly observed stair enclosure between floors enclosed with construction having a fire-resistance rating of at least one hour. Openings around sprinkler pipe penetrations of the NWS-6-4 stair enclosure were not sealed. Findings include:

1. Observation at 11:15 a.m. on 9/24/13 revealed unsealed openings around sprinkler pipe penetrations of the NWS-6-4 stair enclosure. Interview with the plant operations manager at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to provide proper signage at one of one location (powered horizontal sliding exit doors from the emergency department). Findings include:

1. Observation at 10:05 a.m. on 9/25/13 revealed horizontal sliding exit doors from the emergency department. Those doors were operated by power upon approach of a person. In the event of power failure, those doors should have been provided with readily visible signage that read "IN EMERGENCY, PUSH TO OPEN." Those doors were not provided with the required signage. Interview with the plant operation manager at the time of observation confirmed that condition.