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Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. One randomly observed corridor door (director of nursing's office) was held in the open position by an unapproved device. Findings include:

1. Observation at 1:30 p.m. revealed the corridor door to the director of nursing's office was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the maintenance director at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One door (doctors lounge) was provided with double-action latching hardware. Findings include:

1. Observation and interview at 1:03 p.m. revealed the door to the doctors lounge had double-action latching hardware. That door had a sliding barrel-bolt lock mounted at the top of the door. That sliding barrel-bolt lock created a condition where two actions had to be performed to leave the room. That double-action hardware would impede opening the door in an emergency. Interview with the maintenance director at the time of the observation revealed the sliding barrel-bolt lock had been installed because they had recently installed an ADA compliant toilet in the bathroom for that room. That instillation also required the door to the bathroom to be removed and the sliding barrel-bolt lock was installed for privacy. He further stated he would remove the double action hardware as soon as possible and replace it with the appropriate single action hardware.

Based on observation and interview, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping a gurney in the north wing exit corridor. The gurney was kept in that corridor by staff for easy access. Findings include:

1. Observation at 1:02 p.m. revealed a gurney was stored in the north wing exit corridor near the emergency room door. That gurney reduced the corridor width at that point of the corridor from eight feet one inch (97 inches) to five feet nine inches (69 inches). Interview with the maintenance director at the time of the observation confirmed that condition.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring. (See the above attachments.)

Based on observation and interview, the provider failed to furnish permanent wiring in one randomly observed location. Power strips were in use in place of permanent wiring in the emergency room scrub room closet. Findings include:

1. Observation at 2:02 p.m. revealed two power strips were in-use in place of permanent wiring in the emergency room scrub room closet. Those power strips were used to power battery chargers for positive-pressure air-purifying respirators (PPAR). Those power strips had been installed within newly installed cabinets in that room. Interview with the maintenance director at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) dispensers at two randomly observed locations (treatment room and patient room 108). Findings include:

1. Observation beginning at 11:30 a.m. and ending at 3:00 p.m. revealed ABHR dispensers were installed adjacent to an electrical source in the treatment room and patient room 108. Further observation revealed the ABHR in room 108 had been installed over a carpeted floor. Interview at the time of the observation with the maintenance director confirmed those findings.

Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. One randomly observed corridor door (director of nursing's office) was held in the open position by an unapproved device. Findings include:

1. Observation at 1:30 p.m. revealed the corridor door to the director of nursing's office was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the maintenance director at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One door (doctors lounge) was provided with double-action latching hardware. Findings include:

1. Observation and interview at 1:03 p.m. revealed the door to the doctors lounge had double-action latching hardware. That door had a sliding barrel-bolt lock mounted at the top of the door. That sliding barrel-bolt lock created a condition where two actions had to be performed to leave the room. That double-action hardware would impede opening the door in an emergency. Interview with the maintenance director at the time of the observation revealed the sliding barrel-bolt lock had been installed because they had recently installed an ADA compliant toilet in the bathroom for that room. That instillation also required the door to the bathroom to be removed and the sliding barrel-bolt lock was installed for privacy. He further stated he would remove the double action hardware as soon as possible and replace it with the appropriate single action hardware.

Based on observation and interview, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping a gurney in the north wing exit corridor. The gurney was kept in that corridor by staff for easy access. Findings include:

1. Observation at 1:02 p.m. revealed a gurney was stored in the north wing exit corridor near the emergency room door. That gurney reduced the corridor width at that point of the corridor from eight feet one inch (97 inches) to five feet nine inches (69 inches). Interview with the maintenance director at the time of the observation confirmed that condition.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring. (See the above attachments.)

Based on observation and interview, the provider failed to furnish permanent wiring in one randomly observed location. Power strips were in use in place of permanent wiring in the emergency room scrub room closet. Findings include:

1. Observation at 2:02 p.m. revealed two power strips were in-use in place of permanent wiring in the emergency room scrub room closet. Those power strips were used to power battery chargers for positive-pressure air-purifying respirators (PPAR). Those power strips had been installed within newly installed cabinets in that room. Interview with the maintenance director at the time of the observation confirmed that condition.