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

1. Observation on 11/01/10 at 8:45 a.m. revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 12/20/06 confirmed the above condition.

The facility meets the fire safety evaluation system (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 document review, the provider failed to maintain stair enclosure (south stair) between floors enclosed with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 9:30 a.m. on 11/02/10 revealed the one hour fire-rated door to the south stair enclosure on the second floor/patient wing would not close and latch into the frame with the closer. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The basement storage room was being used for combustible storage but did not have adequate separation from the corridor. The hollow core doors for the room were not equipped with closers. Findings include:

1. Observation at 3:45 p.m. on 11/01/10 revealed the basement storage room was over 100 square feet with combustible storage (paper towel products). The room was sprinklered, but the hollow-core corridor doors were not equipped with closers. Interview with the director of plant operations confirmed those conditions.

Based on observation, interview, and document review, the provider failed to maintain conforming exit stairways in five randomly observed locations: south stairs; northwest stairs; east stairs; west stairs; and the north stairs. Findings include:

1. Observation on 11/02/10 at 10:15 a.m. revealed handrails were not provided on both sides of the stairwell in the south stairs and at the top of the landing of the northwest stairs. The south stairs were 39 inches wide. The northwest stairs were 50 inches wide.

2. Observation on 11/02/10 at 10:30 a.m. revealed the interior landing in front of the exterior exit door in the south stairs sloped up approximately six inches to the door threshold.

3. Observation on 11/02/10 between 1:00 p.m. and 1:30 p.m. revealed the following door openings into stair enclosures reduced the landing widths to less than 22 inches:
- The door opening into the first floor east stairs reduced the landing to 15 inches.
- The door opening into the first floor west stairs reduced the landing to 19 inches.
- The door opening into the first floor north stairs reduced the landing to 17 1/2 inches.

4. Interview with the director of plant operations at the time of the above observations confirmed those findings. Review of previous survey documents dated 12/20/06 confirmed the above findings.

The building 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 ensure exits were readily accessible at all times. Two paths of egress had doors that were locked and required keys to facilitate egress at the generator room and the 3rd floor vestible for the 2nd patient elevator. Findings include:

1. Observation and interview beginning at 8:30 a.m. on 11/02/10 revealed the doors for the 3rd floor vestibule of the 2nd patient elevator had keyed locks on the vestibule side of the doors (one to the roof, the second to the 3rd floor of the hospital). Interview with the director of plant operations at the time of the observation revealed the doors were locked at the end of the business day (approximately 5 p.m.) each day to prevent visitors or patients from accessing those areas. The only means of egress was then to return to the lower floors with the elevator.

2. Observation and interview at 9:30 a.m. revealed the exterior door for the generator room (in the high voltage main electrical room) was locked and required a key to unlock the door in order to exit through that door. Interview with the director of plant operations revealed the door was locked to prevent anyone entering the room from outside the building.

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

1. Observation on 11/01/10 at 3:45 p.m. revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system.

Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 12/20/06 confirmed the above findings.

The facility meets the fire safety evaluation system (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 document review, and interview, the provider failed to maintain a conforming exit stairway at the northwest stair enclosure. The stair enclosure did not have a gate to prevent exit travel into the basement from the level of exit discharge. Findings include:

1. Observation on 11/02/10 at 9:45 a.m. revealed the northwest stair was not equipped with a gate barrier to prevent exit travel into the basement from the level of exit discharge. Review of the previous survey document dated 12/20/06 confirmed that condition existed previously. Interview with the director of plant operations at the time of the observation revealed a gate had been installed on another stair enclosure in the past to correct a similar condition.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers at three randomly observed locations. ABHR was found over or adjacent to light switches or electrical receptacles in emergency room 5, endoscopy, and the elevator controls. Findings include:

1. Observation beginning at 3:30 p.m. to 4:30 p.m. revealed ABHR containers installed adjacent to an electrical source in emergency room 5, endoscopy, and at the the elevator controls. Interview with the director of plant operations revealed he was aware the containers were not installed correctly, and the supplier was scheduled to come to the facility and relocate the ABHR containers. He further stated the containers had been in place several years prior to the survey.

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

1. Observation on 11/01/10 at 8:45 a.m. revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 12/20/06 confirmed the above condition.

The facility meets the fire safety evaluation system (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 document review, the provider failed to maintain stair enclosure (south stair) between floors enclosed with construction having a fire-resistance rating of at least one hour. Findings include:

1. Observation at 9:30 a.m. on 11/02/10 revealed the one hour fire-rated door to the south stair enclosure on the second floor/patient wing would not close and latch into the frame with the closer. Interview with the director of plant operations at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The basement storage room was being used for combustible storage but did not have adequate separation from the corridor. The hollow core doors for the room were not equipped with closers. Findings include:

1. Observation at 3:45 p.m. on 11/01/10 revealed the basement storage room was over 100 square feet with combustible storage (paper towel products). The room was sprinklered, but the hollow-core corridor doors were not equipped with closers. Interview with the director of plant operations confirmed those conditions.

Based on observation, interview, and document review, the provider failed to maintain conforming exit stairways in five randomly observed locations: south stairs; northwest stairs; east stairs; west stairs; and the north stairs. Findings include:

1. Observation on 11/02/10 at 10:15 a.m. revealed handrails were not provided on both sides of the stairwell in the south stairs and at the top of the landing of the northwest stairs. The south stairs were 39 inches wide. The northwest stairs were 50 inches wide.

2. Observation on 11/02/10 at 10:30 a.m. revealed the interior landing in front of the exterior exit door in the south stairs sloped up approximately six inches to the door threshold.

3. Observation on 11/02/10 between 1:00 p.m. and 1:30 p.m. revealed the following door openings into stair enclosures reduced the landing widths to less than 22 inches:
- The door opening into the first floor east stairs reduced the landing to 15 inches.
- The door opening into the first floor west stairs reduced the landing to 19 inches.
- The door opening into the first floor north stairs reduced the landing to 17 1/2 inches.

4. Interview with the director of plant operations at the time of the above observations confirmed those findings. Review of previous survey documents dated 12/20/06 confirmed the above findings.

The building 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 ensure exits were readily accessible at all times. Two paths of egress had doors that were locked and required keys to facilitate egress at the generator room and the 3rd floor vestible for the 2nd patient elevator. Findings include:

1. Observation and interview beginning at 8:30 a.m. on 11/02/10 revealed the doors for the 3rd floor vestibule of the 2nd patient elevator had keyed locks on the vestibule side of the doors (one to the roof, the second to the 3rd floor of the hospital). Interview with the director of plant operations at the time of the observation revealed the doors were locked at the end of the business day (approximately 5 p.m.) each day to prevent visitors or patients from accessing those areas. The only means of egress was then to return to the lower floors with the elevator.

2. Observation and interview at 9:30 a.m. revealed the exterior door for the generator room (in the high voltage main electrical room) was locked and required a key to unlock the door in order to exit through that door. Interview with the director of plant operations revealed the door was locked to prevent anyone entering the room from outside the building.

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

1. Observation on 11/01/10 at 3:45 p.m. revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system.

Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 12/20/06 confirmed the above findings.

The facility meets the fire safety evaluation system (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 document review, and interview, the provider failed to maintain a conforming exit stairway at the northwest stair enclosure. The stair enclosure did not have a gate to prevent exit travel into the basement from the level of exit discharge. Findings include:

1. Observation on 11/02/10 at 9:45 a.m. revealed the northwest stair was not equipped with a gate barrier to prevent exit travel into the basement from the level of exit discharge. Review of the previous survey document dated 12/20/06 confirmed that condition existed previously. Interview with the director of plant operations at the time of the observation revealed a gate had been installed on another stair enclosure in the past to correct a similar condition.