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Based on observation and record review, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation at 10:30 a.m. revealed the original building was a two story, protected, ordinary Type III (200) structure with a basement. The building was not provided with a complete automatic sprinkler system. The top floor and attic were equipped with automatic sprinkler protection. Document review of previous survey data confirmed that construction type.

The facility meets 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 the 30 minute fire resistance rating of corridor wall assemblies. Findings include:

1. Observation at 10:00 a.m. revealed the corridor walls extended only approximately six inches above the lay-in acoustical ceiling but did not extend to the roof deck. Document review of previous survey reports also identified that condition.

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, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the basement. One randomly observed door to the corridor (kitchen) would not close and latch . Findings include:

1. Observation and testing at 9:34 a.m. revealed the door from the kitchen to the corridor would not latch into the door frame upon closing when tested. Further testing revealed that door's latch was retracted into the door and would not release. Further observation at that same time revealed that door was equipped with a kick-down device holding the door in the open position. That device was an impediment to closing the door in an emergency. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he was unaware that door was not functioning and kick-down devices were not allowed.

Based on observation and document review, the provider failed to ensure the original elevator had a fire resistive rating of at least one hour. Findings include:

1. Observation at 10:30 a.m. revealed the original elevator doors were not a fire rated assembly and contained a wire glass vision panel approximately 11 inches by 35 inches. Document review of previous survey reports also confirmed that elevator did not have a one-hour fire-resistive rating.

The building meets the FSES. Please mark an "F" in the 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 the 60 minute fire resistive rating of door assemblies. Two randomly observed elevator lobby doors (first and second floors) did not fully close and latch into their frames upon release from the magnetic hold open device. Findings include:

1. Observation at 2:10 p.m. revealed the fist floor elevator lobby 60 minute fire rated self-closing door did not latch into the frame when allowed to self-close from the open position. Further observation at the same time revealed that condition existed in the same location on the second floor. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain proper separation in two randomly observed hazardous areas (trash storage room and radiation [x-ray] room). Findings include:

1. Observation at 9:34 a.m. on 2/15/11 revealed the door to the trash storage room was equipped with a kick-down device to hold the door in the open position. That kick-down device would prevent the door from closing and providing the required fire separation for that room. Interview with the maintenance supervisor at the time of observation confirmed that condition. He stated he was not aware that device was not allowed to be installed on that door.

2. Observation at 10:52 a.m. on 2/15/11 revealed the radiation room had a curtain separating the x-ray area from an area that stored processed x-ray film on open shelving units. That area contained three banks of shelving units. Those shelving units measured approximately eight feet in height and nine feet in length. The amount of combustibles stored in that room and the size of that room (over 50 square feet) made the room a hazardous area. Further observation revealed the radiation room was not protected as a hazardous area. That room did not contain automatic sprinkler protection, the doors to that room were not equipped with automatic closers, and the rooms corridor doors were not fire rated. Interview with the maintenance supervisor at the time of the observations confirmed those conditions.

Based on observation and interview, the provider failed to maintain a clear path of exit to the public way for one of five exits (south stairwell). The stairs were covered with snow and ice. Findings include:

1. Observation at 9:49 a.m. revealed the exit from the south stair enclosure had not been completely cleared of snow and ice. One half the width of the metal exerior stairs were covered with snow and ice That snow and ice would impede egress in the event of an emergency. Interview with the maintenance supervisor at the time of the observation revealed he was not aware that exit had not been cleared. He stated that exit must have been missed.

A. Based on observation, the provider failed to ensure staff were familiar with the facility's fire drill procedures. Findings include:

1. Observation at 9:56 p.m. on 2/15/11 revealed the staff member discovering the simulated fire did not activate the manual fire alarm pull station to alert other staff. Further observation revealed the staff member also required verbal instructions from the fire drill coordinator to initiate and complete the remaining steps of the fire plan. Those steps were to check the door for excessive heat and respond with a fire extinguisher.

B. Based on record review and interview, the provider failed to conduct quarterly fire drills for the two shifts during one of the four previous quarters for the 12 month period beginning July 2010. Findings include:

1. Fire drill record review revealed no documentation indicating fire drills had been conducted for the second shift (7 p.m.-2 a.m.) during the third quarter of 2010 (July through September). Interview with the maintenance supervisor at the time of the record review revealed he was unaware a fire drill had not been held for the identified shift in that quarter.

Based on observation and record review, the provider failed to install a complete automatic sprinkler system as required for the building construction type. Findings include:

1. Observation at 10:20 a.m. revealed the original building was a two story, protected, ordinary Type III (200) structure with a basement. The building was not provided with a complete automatic sprinkler system. The top floor and attic were equipped with sprinkler protection. Document review of previous survey data confirmed a complete automatic sprinkler system had not been provided.

The facility 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 conduct required inspections for one of three boilers. Findings include:

1. Observation at 11:32 a.m. on 2/15/11 revealed an installed boiler did not have a matching boiler inspection certificate. The new boiler was a water heater style A.O. Smith brand, upright unit with 315,000 British Thermal Units (BTU) input for the oil-fired appliance. All oil-fired water heaters with over 199,999 BTU input are considered boilers and require inspection and certification. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he was unaware of the requirement for an inspection certificate for that device.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit on the emergency power system at the transfer switch location. The provider must comply with the National Fire Protection Association (NFPA) 110 The National Generator Code, (see attached: section 5-3.1). Findings include:

1. Observation at 11:20 a.m. revealed the provider failed to install a emergency battery powered lighting unit on the emergency power system at the transfer switch location in the boiler room. Interview with the maintenance supervisor at the time of the observation revealed he was not aware of the requirements for the emergency lighting.

Based on interview and document review, the provider failed to conduct five minute cool down periods following the required thirty minute monthly emergency generator load tests for 2010. Findings include:

1. Interview with a maintenance supervisor at 12:20 p.m. on 2/15/11 revealed the emergency generator was exercised regularly. However the exercise with load being conducted for the full thirty minuets did not include the proper cool down time. The maintenance supervisor indicated he was unaware of the requirement for the five minute cool down period following the full load test and had never performed one. Review of the 2010 generator log confirmed that finding.

A. Based on observation and interview, the provider failed to furnish covers on one randomly observed electrical junction box in the basement copying room. Findings include:

1. Observation beginning at 2:15 p.m. revealed an electrical junction box without a cover in the basement copying room. Interview with the maintenance supervisor at the time of observation confirmed that condition. He stated he was unaware that junction box was not covered, but he would cover it as soon as possible.

B. Based on observation and interview, the provider failed to install permanent wiring for the maintenace office room. A power strip and extension cord were used in place of permanent wiring. (See attached (NFPA 70) Article 305 Temporary Installations.) Findings include:

1. Observation at 10:12 a.m. revealed a power strip was connected to an extension cord that ran over the door and affixed along the north wall to provide power at the workbench. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he was unaware those devices were not permitted to be used as perminant wiring.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers in two randomly observed rooms. (over or adjacent to light switches or electrical receptacles in the laboratory room [lab] and the x-ray office). Findings include:

1. Observation beginning at 10:30 a.m. revealed ABHR containers installed adjacent to electrical sources in the lab and the x-ray office. Interview with the maintenace supervisor confirmed those findings. He stated he would relocate the ABHR containers to acceptable locations as soon as possible.

Based on observation and record review, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation at 10:30 a.m. revealed the original building was a two story, protected, ordinary Type III (200) structure with a basement. The building was not provided with a complete automatic sprinkler system. The top floor and attic were equipped with automatic sprinkler protection. Document review of previous survey data confirmed that construction type.

The facility meets 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 the 30 minute fire resistance rating of corridor wall assemblies. Findings include:

1. Observation at 10:00 a.m. revealed the corridor walls extended only approximately six inches above the lay-in acoustical ceiling but did not extend to the roof deck. Document review of previous survey reports also identified that condition.

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, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the basement. One randomly observed door to the corridor (kitchen) would not close and latch . Findings include:

1. Observation and testing at 9:34 a.m. revealed the door from the kitchen to the corridor would not latch into the door frame upon closing when tested. Further testing revealed that door's latch was retracted into the door and would not release. Further observation at that same time revealed that door was equipped with a kick-down device holding the door in the open position. That device was an impediment to closing the door in an emergency. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he was unaware that door was not functioning and kick-down devices were not allowed.

Based on observation and document review, the provider failed to ensure the original elevator had a fire resistive rating of at least one hour. Findings include:

1. Observation at 10:30 a.m. revealed the original elevator doors were not a fire rated assembly and contained a wire glass vision panel approximately 11 inches by 35 inches. Document review of previous survey reports also confirmed that elevator did not have a one-hour fire-resistive rating.

The building meets the FSES. Please mark an "F" in the 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 the 60 minute fire resistive rating of door assemblies. Two randomly observed elevator lobby doors (first and second floors) did not fully close and latch into their frames upon release from the magnetic hold open device. Findings include:

1. Observation at 2:10 p.m. revealed the fist floor elevator lobby 60 minute fire rated self-closing door did not latch into the frame when allowed to self-close from the open position. Further observation at the same time revealed that condition existed in the same location on the second floor. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain proper separation in two randomly observed hazardous areas (trash storage room and radiation [x-ray] room). Findings include:

1. Observation at 9:34 a.m. on 2/15/11 revealed the door to the trash storage room was equipped with a kick-down device to hold the door in the open position. That kick-down device would prevent the door from closing and providing the required fire separation for that room. Interview with the maintenance supervisor at the time of observation confirmed that condition. He stated he was not aware that device was not allowed to be installed on that door.

2. Observation at 10:52 a.m. on 2/15/11 revealed the radiation room had a curtain separating the x-ray area from an area that stored processed x-ray film on open shelving units. That area contained three banks of shelving units. Those shelving units measured approximately eight feet in height and nine feet in length. The amount of combustibles stored in that room and the size of that room (over 50 square feet) made the room a hazardous area. Further observation revealed the radiation room was not protected as a hazardous area. That room did not contain automatic sprinkler protection, the doors to that room were not equipped with automatic closers, and the rooms corridor doors were not fire rated. Interview with the maintenance supervisor at the time of the observations confirmed those conditions.

Based on observation and interview, the provider failed to maintain a clear path of exit to the public way for one of five exits (south stairwell). The stairs were covered with snow and ice. Findings include:

1. Observation at 9:49 a.m. revealed the exit from the south stair enclosure had not been completely cleared of snow and ice. One half the width of the metal exerior stairs were covered with snow and ice That snow and ice would impede egress in the event of an emergency. Interview with the maintenance supervisor at the time of the observation revealed he was not aware that exit had not been cleared. He stated that exit must have been missed.

A. Based on observation, the provider failed to ensure staff were familiar with the facility's fire drill procedures. Findings include:

1. Observation at 9:56 p.m. on 2/15/11 revealed the staff member discovering the simulated fire did not activate the manual fire alarm pull station to alert other staff. Further observation revealed the staff member also required verbal instructions from the fire drill coordinator to initiate and complete the remaining steps of the fire plan. Those steps were to check the door for excessive heat and respond with a fire extinguisher.

B. Based on record review and interview, the provider failed to conduct quarterly fire drills for the two shifts during one of the four previous quarters for the 12 month period beginning July 2010. Findings include:

1. Fire drill record review revealed no documentation indicating fire drills had been conducted for the second shift (7 p.m.-2 a.m.) during the third quarter of 2010 (July through September). Interview with the maintenance supervisor at the time of the record review revealed he was unaware a fire drill had not been held for the identified shift in that quarter.

Based on observation and record review, the provider failed to install a complete automatic sprinkler system as required for the building construction type. Findings include:

1. Observation at 10:20 a.m. revealed the original building was a two story, protected, ordinary Type III (200) structure with a basement. The building was not provided with a complete automatic sprinkler system. The top floor and attic were equipped with sprinkler protection. Document review of previous survey data confirmed a complete automatic sprinkler system had not been provided.

The facility 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 conduct required inspections for one of three boilers. Findings include:

1. Observation at 11:32 a.m. on 2/15/11 revealed an installed boiler did not have a matching boiler inspection certificate. The new boiler was a water heater style A.O. Smith brand, upright unit with 315,000 British Thermal Units (BTU) input for the oil-fired appliance. All oil-fired water heaters with over 199,999 BTU input are considered boilers and require inspection and certification. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he was unaware of the requirement for an inspection certificate for that device.

Based on observation and interview, the provider failed to install an emergency battery powered lighting unit on the emergency power system at the transfer switch location. The provider must comply with the National Fire Protection Association (NFPA) 110 The National Generator Code, (see attached: section 5-3.1). Findings include:

1. Observation at 11:20 a.m. revealed the provider failed to install a emergency battery powered lighting unit on the emergency power system at the transfer switch location in the boiler room. Interview with the maintenance supervisor at the time of the observation revealed he was not aware of the requirements for the emergency lighting.

Based on interview and document review, the provider failed to conduct five minute cool down periods following the required thirty minute monthly emergency generator load tests for 2010. Findings include:

1. Interview with a maintenance supervisor at 12:20 p.m. on 2/15/11 revealed the emergency generator was exercised regularly. However the exercise with load being conducted for the full thirty minuets did not include the proper cool down time. The maintenance supervisor indicated he was unaware of the requirement for the five minute cool down period following the full load test and had never performed one. Review of the 2010 generator log confirmed that finding.

A. Based on observation and interview, the provider failed to furnish covers on one randomly observed electrical junction box in the basement copying room. Findings include:

1. Observation beginning at 2:15 p.m. revealed an electrical junction box without a cover in the basement copying room. Interview with the maintenance supervisor at the time of observation confirmed that condition. He stated he was unaware that junction box was not covered, but he would cover it as soon as possible.

B. Based on observation and interview, the provider failed to install permanent wiring for the maintenace office room. A power strip and extension cord were used in place of permanent wiring. (See attached (NFPA 70) Article 305 Temporary Installations.) Findings include:

1. Observation at 10:12 a.m. revealed a power strip was connected to an extension cord that ran over the door and affixed along the north wall to provide power at the workbench. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he was unaware those devices were not permitted to be used as perminant wiring.