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Based on observation, testing, and interview, the provider failed to maintain proper separation in three of three randomly observed hazardous areas (the boiler room near the ICU (intensive care unit), the soiled utility near the nurses' station and the storage room near the interior stairway) are considered hazardous areas. Findings include:

1. Observation at 10:30 a.m. on 09/10/13 revealed a boiler room near the ICU with direct access to the corridor. The door from that room into the corridor door was not provided with a self-closing device. Penetrations for sprinkler piping from that room into the corridor were not properly sealed to prevent the passage of smoke.

2. Observation at 10:45 a.m. on 09/10/13 revealed a storage room near the interior stairway that was over 50 square feet and was being used to store combustible material. That room is considered a hazardous area and shall be provided with smoke resisting partitions and doors with a self-closing device. The door from that room into the corridor door was not provided with a self-closing device.

3. Observation and testing at 11:40 a.m. on 09/10/13 revealed a soiled utility room near the nurses' station. That room is considered a hazardous area and shall be provided with smoke resisting partitions and doors with a self-closing device. The door to that room would rub against its frame and could not be closed with the doors self-closing device. That affected the fire and smoke rating of the door.

4. Interview with maintenance staff at the time of those observations revealed he was unaware of those requirements. He believed those doors were on a preventative maintenance checklist. Further interview and review of the preventative maintenance program revealed those doors were not checked regularly for proper operation.

Based on observation and interview, the provider failed to maintain exit signs with continuous illumination for two randomly observed exit signs (exit signage into the stair enclosure from the men's and women's locker rooms and directional exit signage near the entrance into the post operation suite). Findings include:

1. Observation beginning at 9:30 a.m. on 9/10/13 revealed the exit signage into the stair enclosure from the men's and women's locker rooms and directional exit signage near the entrance into the post operation suite both had burned out bulbs. Interview with the maintenance staff at the time of observation confirmed those conditions. He did not indicate if a preventive maintenance program was provided for ensuring those signs had bulbs that worked.

Based on observation and interview, the provider failed to ensure staff were familiar with the fire drill procedures and failed to conduct quarterly fire drills each shift during one of the four previous quarters (April 2013 to June 2013). Findings include:

1. Observation at 2:30 p.m. on 9/10/13 during the fire drill revealed staff did not remove all obstructions from the corridor for a clear and unobstructed path. The mobile medical computers outside the patients' rooms impeded the required clear width of the corridor. Those computers should have been removed from the corridor. Interview with safety staff and the director of plant operations after the fire drill revealed they were unaware of that requirement.

2. Fire drill record review revealed no documentation indicating a fire drill had been conducted during the second quarter of 2013 for the night shift. Exit interview with the plant operation manager at 3:00 p.m. on 9/10/13 revealed he was unaware a fire drill had not been conducted during that time. He believed a fire drill had been done, but it might not have been documented.

Based on observation, testing, and interview the provider failed to maintain the generator in accordance with NFPA 110. The battery powered emergency lighting required at the generator was not functioning. Findings include:

1. Observation at 10:00 a.m. on 09/10/13 revealed a generator room that housed a generator capable of supplying backup power for building 01-original construction. That room and generator was provided with an emergency lighting fixture. Testing of that emergency lighting fixture revealed that light was not functioning. Interview with maintenance staff at the time of the testing revealed he was not aware light was not working. He did not believe that light was included on the preventive maintenance checklist.