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Based on observation and document record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code. The fire-rated ceiling of the corridor to the boiler room had unsealed openings. Findings include:

1. Observation at 10:00 a.m. revealed unsealed openings in the fire-rated ceiling of the corridor to the boiler room. Two holes approximately 12 inches by 12 inches each had been cut through the ceiling for hanging piping above the unrated lay-in acoustical ceiling. The 30 foot long corridor was not sprinklered. Review of the previous survey record dated 3/27/07 revealed building 01 (original building) was a single story, noncombustible, Type II (111) structure with a partial basement and without a complete automatic sprinkler system. The unsealed openings would derate the building to a Type II (000) structure without a complete automatic sprinkler system. That building type with a partial sprinkler system did not meet Life Safety Code construction standards.

Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. The door to the supply room (Room 391) was held open with a cart. Findings include:

1. Observation at 10:45 a.m. revealed the corridor door to the supply room (Room 391) was held in the open position with a cart for "Comfort" brand warmers. That device was an impediment to closing the door in an emergency. The door had a label above the latching hardware stating "DO NOT BLOCK DOOR DOOR ON MAGNET." Interview with the maintenance director at the time of the observation confirmed that finding. The cart was removed during the survey.

Based on observation and interview, the provider failed to install vision panels in corridor walls that were fixed window assemblies in approved frames. The admissions office had a sliding glass window measuring approximately 24 inches by 30 inches in the wall shared with the lobby. The chapel had two unrated stained glass windows measuring 30 inches by 30 inches each. Findings include:

1. Observation at 9:45 a.m. revealed the admissions office had a sliding glass window measuring approximately 24 inches by 30 inches in the wall shared with the lobby. The admissions office could be considered common with the corridor system with the installation of a smoke detector hard-wired into the fire alarm system.

2. Observation at 11:00 a.m. revealed the chapel had two unrated stained glass windows measuring 30 inches by 30 inches each. The chapel could be considered common with the corridor system with the installation of a smoke detector hard-wired into the fire alarm system.

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

Based on observation and interview, the provider failed to install smoke detection connected to the fire alarm system at 90 minute fire-rated doors in two hour fire separation walls. Findings Include:

1. Observation at 10:30 a.m. revealed there were no smoke detectors installed connected to the fire alarm system on each side of the 90 minute fire-rated doors in the two hour separating building 01 (original building) and building 02 (1999 addition). Interview with the maintenance director at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to install exit signs for three locations (the two large roof penthouses and the boiler room). Findings include:

1. Observation beginning at 10:30 a.m. revealed the following areas (each over 500 square feet) were not equipped with exit signs: the boiler room and each of the two large penthouses on the roof. Interview with the maintenance director at the time of the observations confirmed those findings.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The medical records storage room was being used for combustible storage and had two corridor doors. The west corridor door was unrated and did not have a closer installed. The electrical panel room corridor door adjacent to the generator room did not have a closer. The environmental services storage room did not have a closer. Findings include:

1. Observation at 10:30 a.m. revealed the 500 square foot medical records storage room was being used for combustible storage and had two corridor doors. The room's west door to the corridor was a 20 minute equivalent solid bonded wood core door (not a 3/4 hour or greater fire-rated door as required). The door also did not have a closer installed. A barrel bolt (an unacceptable application) was installed on the inside of the door.

2. Observation at 10:45 a.m. revealed the 15 foot by 15 foot housekeeping/chemical storage room corridor door was not equipped with a functioning closer. Parts of a closer were on the door, but it was inoperative.

3. Observation at 1:15 p.m. revealed the electrical panel room (adjacent to the generator room) corridor door was not equipped with a closer. The room had a 2000 amp and a 600 amp service feed into the room.

4. Interview with the maintenance director at the time of the observations confirmed those findings.

Based on observation and interview, the provider failed to provide protection against fire or smoke from other parts of the building for the south basement stair level of exit discharge. The corridor door for the vestibule on the main level was not equipped with a closer. Findings include:

1. Observation at 1:45 p.m. revealed the corridor door for the south basement stair vestibule on the main level was not equipped with a closer. The path of escape from the basement was not protected against fire or smoke from other parts of the building. Interview with the maintenance director at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to ensure two exits were readily accessible at all times and were paved to the public way (obstetrics wing and south basement stairs). Findings include:

1. Observation at 1:45 p.m. revealed the obstetrics wing had only a concrete landing at the exterior of the west exit door steps and was not paved to a public way. Interview with the maintenance director at the time of the observation revealed the closest paved road/sidewalk was approximately 200 feet away.

2. Observation at 2:00 p.m. revealed the south basement stairs opened into a 30 foot long enclosure/vestibule had an exterior exit door. The exit discharge had only a concrete landing at the base of the steps and was not paved to a public way. Interview with the maintenance director at the time of the observation revealed the closest paved road/sidewalk was approximately 150 feet away.

Based on observation and interview, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping automobile seats, a stainless steel portable crib, chairs, pad cushions, and medical equipment in the exit discharge corridor from the south basement exit. Findings include:

1. Observation at 1:45 p.m. revealed the exit discharge corridor from the south basement exit was obstructed by automobile seats, a stainless steel portable crib, chairs, pad cushions, and medical equipment in the exit discharge corridor from the south basement exit. Interview with the maintenance director at the time of the observation revealed those items were kept in the exit discharge corridor until they were needed for use by staff.

Based on observation and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition. The alternate swing wood doors in the two hour wall between Building 01 and Building 02 (adjacent to the chapel) did not have floor strike plates. Findings include:

1. Observation at 10:15 a.m. revealed the 90 minute fire-rated cross-corridor alternate-swing horizontal exit wood doors in the two hour wall between the original building and the 1999 addition adjacent to the chapel were equipped with bottom-latching hardware. There were no floor strike plates provided for the bottom-latching hardware. Interview with the maintenance director at the time of the observation confirmed that finding. He stated the floor strikes had not been reinstalled by the contractor who had replaced the flooring.

Based on observation and interview, the provider failed to install exit signs with continuous illumination. The south basement stair main floor exit did not have an exit sign in one randomly observed area (south basement stair main floor exit). Findings include:

1. Observation beginning at 2:00 p.m. revealed the south basement stair main floor exit was not equipped with a lit exit sign on the emergency lighting system at the exit discharge. Interview with the maintenance director at the time of the observation confirmed that finding.

Based on observation, interview, and record review, the provider failed to ensure staff were familiar with fire drill procedures. The number of drills performed did not adequately involve facility staff with fire drills. Findings include:

1. Observation at 12:30 p.m. revealed the fire drill was initiated in the dietary kitchen. Dietary staff were instructed by the maintenance director through the process of paging and announcing the drill, where to activate the manual fire alarm pull station, and to vacate the affected area.

Record review of the previous twelve months fire drills beginning in April 2010 revealed 14 drills had been performed: 4 on the first (day) shift; 6 on the second (evening) shift; and 4 on the third (night) shift for the 100 plus hospital employees. Two of the day shift signup sheets indicated participation of 31 and 27 individuals, respectively in April 2010 and July 2010. No signup information was available for the September and December 2010 day shift fire drills. Of the 6 evening shift fire drills, two dates had participation signup. November 2010 had 8 staff participating; January 2011 had 20 staff participating. Of the 4 night fire drills, two dates had participated signup information: October 2010 with 6 staff and February 2011 with 8 staff signed up. The intent of the fire drill requirement was to have each staff member (nurses, interns, maintenance engineers, and administrative staff) participate in at least one fire drill per quarter. Fire drills should have been scheduled to ensure that personnel were drilled not less than once in each 3-month period. Interview with the maintenance director at 5:00 p.m. during the exit interview revealed more fire drills would be needed to meet the standard.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the required quarterly flow testing performed and documented during the previous twelve months. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor at the time of the record review indicated he was unaware of the quarterly flow testing requirements.

A. Based on observation and staff interview, it was determined the provider failed to install and use baffle type filters in the stove exhaust hood in accordance with NFPA 96. Also, there was not a procedure in place to inspect and clean the hood exhaust duct. Findings include:

1. Observation at 11:15 a.m. revealed the kitchen stove exhaust hood had mesh type filters in the overhead exhaust duct. Baffle type exhaust filters are required for the stove hood exhaust system. Interview with the maintenance director at the time of the observation revealed he had known the facility to only use the wire mesh filters for the exhaust system. He further revealed there was not a schedule in place to inspect and clean the exhaust duct from the hood to the exterior of the building on a regular basis.

B. Based on observation and interview, the provider failed to conduct required inspection of the cooking facility's fire extinguishing system. Inspections of the extinguishing system for the range hood must be conducted not less than every six months. Findings include:

1. Document review revealed the Amerex KP-275 chemical extinguishing system for the kitchen hood was tagged with an inspection tag dated August 26, 2010. There were no inspection reports available for review between the 2007 installation date and the August 26, 2010 inspection. Interview with the maintenance director at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). A structure housing the walk-in cooler/freezer and vestibule to the kitchen was not sprinklered and had exposed structural steel. Findings include:

1. Observation at 10:00 a.m. revealed a building addition on the north side of the kitchen housed the walk-in cooler and freezer and provided a vestibule into the kitchen. The addition had exposed unprotected structural steel that derated the building to a Type II (000) structure. A Type II (000) structure was not allowed for a health care facility unless it was equipped with an automatic fire sprinkler system. Interview with the maintenance director at the time of the observation confirmed that finding. He stated that addition had been built in the 1970's.