HospitalInspections.org

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, 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, 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.