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Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area. The dry storage room for the kitchen contained two doors. The door from the corridor to the dry storage had the door closer removed, and the door from the dry storage to the kitchen was wedged open. Findings include:

1. Observation at 11:00 a.m. revealed the door from the corridor to the dry kitchen storage room would not automatically close and latch into the frame. Upon further observation the automatic door closer had been removed. Interview with the lead maintenance person at the time of the observation confirmed the closer was missing. He was unaware the door closer had been removed.

2. Observation at 11:05 on 2/11/2014 revealed the door from the dry kitchen storage room into the kitchen was held in the open position by a rubber wedge. The wedge was removed, and the door closed. Observation at 11:15 a.m. on 2/11/2014 revealed the rubber door wedge had again been inserted to hold the door in the open position. Interview with the lead maintenance person at the time of the observation confirmed the door was wedged open. He indicated this door was used frequently during food preparation and a magnetic hold open device connected to the facility fire alarm system would be the proper solution.

Based on record review and interview, the provider failed to conduct quarterly fire drills each quarter for the three shifts during one of the four previous quarters between January 2013 through February 2014. Findings include:

1. Fire drill record review revealed no documentation indicating a fire drill was conducted for the third shift (11 p.m.-7 a.m.) during the third quarter 2013 (July through September). Exit interview with the chief financial officer, maintenance director, and lead maintenance person revealed they were unaware fire drills were not held for each quarter. Fire drills were the responsibility of another person within the maintenance department.