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Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation and record review of the previous survey document revealed the building was a two story, protected, non-combustible, Type II (111) structure without an automatic sprinkler system.

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 and interview, the provider failed to protect corridor openings with substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Five randomly observed doors at the south end on the second floor were hollow core doors. Findings include:

1. Observation at 11:30 a.m. revealed five doors on the south part of the second floor were hollow core doors. Interview with the director of maintenance at the time of the observation revealed he believed the doors were part of the original construction (the south part of the second floor was added later). He further revealed several staff members used the second floor to stay overnight occasionally.

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 and interview, the provider failed to maintain proper separation of hazardous areas. The garage used for storage and loading dock had double-doors that were held open with magnetic hold-open devices. The doors did not latch into the frame. The nurses storage room 18 did not meet storage room requirements. Findings include:

1. Observation at 9:30 a.m. revealed the 90 minute fire-rated separation double-doors between the garage/storage/loading dock and the hospital corridor were equipped with magnetic hold-open devices. The north leaf of the double-doors would not latch into the frame. The south leaf latched into the north leaf. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated he was unaware the hold open devices and door latching did not meet code requirements.

2. Observation at 11:00 a.m. revealed nursing supplies were stored in room 18 (designated and designed as a patient room). The room was over 100 square feet in area, was not provided with either fire sprinkler protection or a fire-rated door of 3/4 hour (or higher) with an acceptable self-closing device, was not equipped with exhaust ventilation, and was not separated from the adjacent patient room 20 that shared a common toilet room with room 18. Interview with the maintenance supervisor revealed the storage items were moved there from the central supply storage room in the past year.

Based on observation and record review, the provider failed to maintain a protected path of egress from the second level to the exterior of the building. One of three stairs discharged onto the main level and was not provided with a one hour fire resistive enclosure to the exterior of the building. Findings include:

1. Observation at 11:15 a.m. revealed a second floor spiral stairs discharged into the dining room on the main level. Record review of the previous survey document dated 10/14/08 confirmed that finding. Those stairs were originally used by the nuns who operated the facility to access their dining room from the second level. Those stairs had existed since the building was constructed.

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, record review, and interview, the provider failed to maintain conforming exit stairs. The south stair enclosure in the patient room wing had two storage rooms that opened into the stair enclosure. Findings include:

1. Observation at 10:30 a.m. revealed two storage rooms opened directly into the south stair enclosure in the patient room wings. Review of health department records revealed those two storage rooms had existed since the addition was constructed. That condition was confirmed by an interview with the director of maintenance.

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 and record review, the provider failed to maintain clear door widths of at least 32 inches for two randomly observed set of exit access doors at the loading dock and the service corridor. Findings include:

1. Observation at 10:45 a.m. revealed the leaves for the double-doors entering the loading dock area were only 24 inches wide and did not provide a clear opening width of 32 inches. The cross-corridor doors to the service corridor were also only 24 inches wide. Record review of the previous survey documents revealed those doors had existed since the building was constructed.

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, testing, and interview, the provider failed to maintain emergency lighting of at least one hour duration. Two of three emergency lights on the second floor did not work. Findings include:

1. Observation at 11:00 a.m. revealed three emergency lights were mounted on the second floor of the building. Testing of two of the three lights at the time of the observation revealed the lights did not work. The emergency battery pack light over the stair enclosure was inaccessible for testing. Interview with the director of maintenance revealed he was unaware the two lights tested did not work. He further added he was not sure the third light worked, as he had not been testing those fixtures on a monthly preventive maintenance schedule.

Based on observation and interview, the provider failed to ensure staff were familiar with fire drill procedures. Findings include:

1. Observation at 1:30 p.m. revealed the charge nurse responding to the simulated fire did not pull the manual fire alarm station closest to the fire location to initiate the fire drill. The maintenance supervisor also had to walk the employee through the steps of the fire drill response. Interview with the director of maintenance at the time of the observation revealed the employee was a part-time worker but had worked at the facility for the past year. Review of the previous four quarters (12 months) of fire drills revealed the provider had performed the minimum required amount of fire drills for a two-shift system for that time period. The fire drill form for June 2011 had 19 participating staff signatures, but the form was not filled out. The fire drill forms for July and August 2011 did not have any participating staff signatures.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation revealed the building was a two story, protected non-combustible, Type II (111) structure without an automatic sprinkler system. Review of the previous survey documents confirmed that finding.

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, document review, and interview, the provider failed to conduct required maintenance of the generator as required by the National Fire Protection Association (NFPA) 110. Findings include:

1. Observation at 11:15 a.m. revealed the 150 Kilowatt (Kw) diesel generator had two batteries with only the positive terminals covered. Review of the generator maintenance logs revealed the contractor had noted excessive carbon build-up in the generator exhaust system and had recommended a load bank exercise. Excessive carbon build-up is an indication of wet stacking or light loading of the generator resulting in the presence of unburned fuel or carbon in the exhaust system.

Interview with the maintenace supervisor at the time of the observations revealed he was unaware of the required items noted above. He further stated he was not performing and logging monthly specific gravity tests of the battery water as required by NFPA 110.

Based on observation, testing, and interview, the provider failed to install a correctly wired duplex receptacle that was also a ground fault interruptible circuit (GFCI). One randomly observed duplex receptacle in the hopper room adjacent to the operating room (OR) was incorrectly wired and was not a GFCI circuit receptacle. Findings include:

1. Observation at 10:30 a.m. revealed an electrical duplex receptacle within four feet of a handsink in the cleanup room adjacent to the OR. The receptacle was not a GFCI receptacle. Testing of the receptacle revealed the circuit was wired with an open ground. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he would check and see if the receptacle was required for use by other staff and repair or remove the receptacle accordingly.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) containers at six randomly observed locations. ABHR was found mounted directly above light switches in rooms 14, 26, 37, 38, the utility room, and the nurses station. Findings include:

1. Observation beginning from 9:45 a.m. to 10:45 a.m. revealed ABHR containers installed over an electrical source (light switches) in rooms 14, 26, 37, 38, the utility room, and the nurses station. Interview with the maintenance supervisor at the times of the observations confirmed those conditions. 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 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation and record review of the previous survey document revealed the building was a two story, protected, non-combustible, Type II (111) structure without an automatic sprinkler system.

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 and interview, the provider failed to protect corridor openings with substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Five randomly observed doors at the south end on the second floor were hollow core doors. Findings include:

1. Observation at 11:30 a.m. revealed five doors on the south part of the second floor were hollow core doors. Interview with the director of maintenance at the time of the observation revealed he believed the doors were part of the original construction (the south part of the second floor was added later). He further revealed several staff members used the second floor to stay overnight occasionally.

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 and interview, the provider failed to maintain proper separation of hazardous areas. The garage used for storage and loading dock had double-doors that were held open with magnetic hold-open devices. The doors did not latch into the frame. The nurses storage room 18 did not meet storage room requirements. Findings include:

1. Observation at 9:30 a.m. revealed the 90 minute fire-rated separation double-doors between the garage/storage/loading dock and the hospital corridor were equipped with magnetic hold-open devices. The north leaf of the double-doors would not latch into the frame. The south leaf latched into the north leaf. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated he was unaware the hold open devices and door latching did not meet code requirements.

2. Observation at 11:00 a.m. revealed nursing supplies were stored in room 18 (designated and designed as a patient room). The room was over 100 square feet in area, was not provided with either fire sprinkler protection or a fire-rated door of 3/4 hour (or higher) with an acceptable self-closing device, was not equipped with exhaust ventilation, and was not separated from the adjacent patient room 20 that shared a common toilet room with room 18. Interview with the maintenance supervisor revealed the storage items were moved there from the central supply storage room in the past year.

Based on observation and record review, the provider failed to maintain a protected path of egress from the second level to the exterior of the building. One of three stairs discharged onto the main level and was not provided with a one hour fire resistive enclosure to the exterior of the building. Findings include:

1. Observation at 11:15 a.m. revealed a second floor spiral stairs discharged into the dining room on the main level. Record review of the previous survey document dated 10/14/08 confirmed that finding. Those stairs were originally used by the nuns who operated the facility to access their dining room from the second level. Those stairs had existed since the building was constructed.

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, record review, and interview, the provider failed to maintain conforming exit stairs. The south stair enclosure in the patient room wing had two storage rooms that opened into the stair enclosure. Findings include:

1. Observation at 10:30 a.m. revealed two storage rooms opened directly into the south stair enclosure in the patient room wings. Review of health department records revealed those two storage rooms had existed since the addition was constructed. That condition was confirmed by an interview with the director of maintenance.

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 and record review, the provider failed to maintain clear door widths of at least 32 inches for two randomly observed set of exit access doors at the loading dock and the service corridor. Findings include:

1. Observation at 10:45 a.m. revealed the leaves for the double-doors entering the loading dock area were only 24 inches wide and did not provide a clear opening width of 32 inches. The cross-corridor doors to the service corridor were also only 24 inches wide. Record review of the previous survey documents revealed those doors had existed since the building was constructed.

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, testing, and interview, the provider failed to maintain emergency lighting of at least one hour duration. Two of three emergency lights on the second floor did not work. Findings include:

1. Observation at 11:00 a.m. revealed three emergency lights were mounted on the second floor of the building. Testing of two of the three lights at the time of the observation revealed the lights did not work. The emergency battery pack light over the stair enclosure was inaccessible for testing. Interview with the director of maintenance revealed he was unaware the two lights tested did not work. He further added he was not sure the third light worked, as he had not been testing those fixtures on a monthly preventive maintenance schedule.

Based on observation and interview, the provider failed to ensure staff were familiar with fire drill procedures. Findings include:

1. Observation at 1:30 p.m. revealed the charge nurse responding to the simulated fire did not pull the manual fire alarm station closest to the fire location to initiate the fire drill. The maintenance supervisor also had to walk the employee through the steps of the fire drill response. Interview with the director of maintenance at the time of the observation revealed the employee was a part-time worker but had worked at the facility for the past year. Review of the previous four quarters (12 months) of fire drills revealed the provider had performed the minimum required amount of fire drills for a two-shift system for that time period. The fire drill form for June 2011 had 19 participating staff signatures, but the form was not filled out. The fire drill forms for July and August 2011 did not have any participating staff signatures.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation revealed the building was a two story, protected non-combustible, Type II (111) structure without an automatic sprinkler system. Review of the previous survey documents confirmed that finding.

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, document review, and interview, the provider failed to conduct required maintenance of the generator as required by the National Fire Protection Association (NFPA) 110. Findings include:

1. Observation at 11:15 a.m. revealed the 150 Kilowatt (Kw) diesel generator had two batteries with only the positive terminals covered. Review of the generator maintenance logs revealed the contractor had noted excessive carbon build-up in the generator exhaust system and had recommended a load bank exercise. Excessive carbon build-up is an indication of wet stacking or light loading of the generator resulting in the presence of unburned fuel or carbon in the exhaust system.

Interview with the maintenace supervisor at the time of the observations revealed he was unaware of the required items noted above. He further stated he was not performing and logging monthly specific gravity tests of the battery water as required by NFPA 110.

Based on observation, testing, and interview, the provider failed to install a correctly wired duplex receptacle that was also a ground fault interruptible circuit (GFCI). One randomly observed duplex receptacle in the hopper room adjacent to the operating room (OR) was incorrectly wired and was not a GFCI circuit receptacle. Findings include:

1. Observation at 10:30 a.m. revealed an electrical duplex receptacle within four feet of a handsink in the cleanup room adjacent to the OR. The receptacle was not a GFCI receptacle. Testing of the receptacle revealed the circuit was wired with an open ground. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he would check and see if the receptacle was required for use by other staff and repair or remove the receptacle accordingly.