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Based on observation, testing, and interview, the provider failed to maintain 90 minute fire separation doors in operating condition. One randomly observed set of cross-corridor fire separation doors at the building separation between the clinic and the hospital did not properly close and latch when closed with the closers. Findings include:

1. Observation and testing at 3:15 p.m. revealed the cross-corridor fire separation doors at the connection of the clinic and the hospital did not properly close and latch when closed with the automatic door closers. Those doors were part of the two hour fire-resistive separation between the clinic and the hospital. They must properly close and latch to maintain the fire-resistive rating of that separation. Testing of those doors several times with the plant operations supervisor revealed the doors would bind on each other keeping them from properly closing and latching. Interview with the plant operations supervisor at the time of the observation and testing confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the north wing. Two randomly observed doors (staff lounge and the vacuum/data room) to the corridor would not close and latch. Findings include:

1. Observation and testing at 1:49 p.m. revealed the corridor door to the staff lounge did not properly close and latch into the door frame under power of the automatic door closer when tested. Interview with the plant operations supervisor at the time of the observation confirmed that condition.

Based on observation, testing, and interview, the provider failed to maintain self-closing smoke barrier doors on one randomly observed smoke barrier door (west of the director of nursing [DON] office). Findings include:

1. Observation at 2:10 p.m. revealed the one hour rated, cross-corridor, smoke barrier door in the corridor directly to the west of the DON's office would not fully close upon release of the magnetic hold open. Testing of that door revealed the door was striking the door frame in the top corner and would not properly close. Interview at the time of the observation with the plant operations supervisor confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. The corridor door to the boiler/HVAC room would not close and latch into the frame. Findings include:

1. Observation and testing at 1:44 p.m. on 6/7/11 revealed the east corridor door to the boiler/HVAC room had the latch taped over with duct tape to keep the door from latching. Further observation revealed the strike plate of the door frame was also taped over to keep the door from latching into the frame. The plant operations supervisor stated he had not noticed that door was not properly latching. He stated he believed the contractors that were removing the facilities boilers had taped the door open to let cool air into their work area.

Based on interview, the provider failed to ensure emergency lighting of at least 90 minute duration was provide at all times (at the generator transfer switch). Findings include:

1. Interview with the plant operations supervisor at 4:47 p.m. on 6/7/11 revealed he did not have documented testing of the emergency light for the transfer switch in the boiler room on the preventive maintenance schedule. He stated he did not have a written schedule for the required monthly and yearly tests required for that device, but he tested it monthly.

Based on record review and interview, the provider failed to conduct quarterly fire drills for two of the three shifts during two of the four previous quarters for the 12 month period beginning June 2011. Findings include:

1. Fire drill record review revealed no documentation indicating fire drills had been conducted for the third shift (10 p.m.-6 a.m.) in the second quarter (April through June) of 2010 or the second shift (10 p.m.-6 a.m.) during the fourth quarter of 2010 (October through December). Interview with the plant operations supervisor at the time of the observation confirmed that finding. He stated the provider had been cited for the same issue during the 2011 survey for the attached nursing home since they held fire drills at the same time.

Based on observation and interview, the provider failed to furnish two means for transmitting the fire alarm system signal to an approved central station. The fire alarm systems communication device only had one phone line connected to it to signal the monitoring agency. A minimum of two means (two phone lines) for transmitting a signal offsite is required per NFPA 72, section 5-5.3.2.1.6.1. Findings include:

1. Observation at 1:38 p.m. revealed the fire alarm panel had a communication device with only one means for transmitting a signal off site (one telephone line) and not two as required by a digital alarm communicating transmitter (DACT). Interview with the plant operations supervisor at the time of the observation indicated he was not aware of the need for the second telephone line and would be getting a second line installed as soon as possible.

Based on observation and interview, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping a scale and a patient lift in the west patent sleeping wing corridor. Those items were kept in the corridor by staff for easy access. Findings include:

1. Observation at 3:08 p.m. revealed a fold-up scale and a patient lift were stored in the alcove at the end of the west patient sleeping wing corridor. Those items were placed, so they restricted the corridor width by 28 inches. Interview with the plant operations supervisor at the time of the observation confirmed that condition. The plant operations supervisor repositioned the patent lift and folded up the scale, so they would both fit into the alcove space and not impede the clear path of egress.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring and article 210-8 Ground-Fault Circuit-Interrupter Protection for Personnel. (See the above attachments.)

Based on observation and interview, the provider failed to furnish permanent wiring. Power strips were in-use in place of permanent wiring in the maintenance shop. Findings include:

1. Observation at 1:33 p.m. revealed a power strip in-use in place of permanent wiring in the maintenace shop. That power strip was used to power various items on the workbench as well as another power strip that was powering battery chargers for cordless power tools. Additionally the two incandecent lights placed on either side of the top of the workbench were wired using a lamp cord and barn style light fixtures. Interview with the plant operations supervisor at the time of the observation confirmed that condition. He stated that condition had existed as long as he could remember. He could not recall when those items had been placed into service.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) dispensers in one randomly observed room (patient sleeping room nine ). Findings include:

1. Observation at 4:14 p.m. revealed an ABHR dispenser was installed over an electrical source in patient sleeping room nine. Interview at the time of the observation with the plant operations supervisor confirmed that finding. He stated he believed most of the patient sleeping rooms would also have that same condition. He further stated he would relocate the ABHR dispensers to acceptable locations as soon as possible.

Based on observation, testing, and interview, the provider failed to maintain 90 minute fire separation doors in operating condition. One randomly observed set of cross-corridor fire separation doors at the building separation between the clinic and the hospital did not properly close and latch when closed with the closers. Findings include:

1. Observation and testing at 3:15 p.m. revealed the cross-corridor fire separation doors at the connection of the clinic and the hospital did not properly close and latch when closed with the automatic door closers. Those doors were part of the two hour fire-resistive separation between the clinic and the hospital. They must properly close and latch to maintain the fire-resistive rating of that separation. Testing of those doors several times with the plant operations supervisor revealed the doors would bind on each other keeping them from properly closing and latching. Interview with the plant operations supervisor at the time of the observation and testing confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the north wing. Two randomly observed doors (staff lounge and the vacuum/data room) to the corridor would not close and latch. Findings include:

1. Observation and testing at 1:49 p.m. revealed the corridor door to the staff lounge did not properly close and latch into the door frame under power of the automatic door closer when tested. Interview with the plant operations supervisor at the time of the observation confirmed that condition.

Based on observation, testing, and interview, the provider failed to maintain self-closing smoke barrier doors on one randomly observed smoke barrier door (west of the director of nursing [DON] office). Findings include:

1. Observation at 2:10 p.m. revealed the one hour rated, cross-corridor, smoke barrier door in the corridor directly to the west of the DON's office would not fully close upon release of the magnetic hold open. Testing of that door revealed the door was striking the door frame in the top corner and would not properly close. Interview at the time of the observation with the plant operations supervisor confirmed that finding.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. The corridor door to the boiler/HVAC room would not close and latch into the frame. Findings include:

1. Observation and testing at 1:44 p.m. on 6/7/11 revealed the east corridor door to the boiler/HVAC room had the latch taped over with duct tape to keep the door from latching. Further observation revealed the strike plate of the door frame was also taped over to keep the door from latching into the frame. The plant operations supervisor stated he had not noticed that door was not properly latching. He stated he believed the contractors that were removing the facilities boilers had taped the door open to let cool air into their work area.

Based on interview, the provider failed to ensure emergency lighting of at least 90 minute duration was provide at all times (at the generator transfer switch). Findings include:

1. Interview with the plant operations supervisor at 4:47 p.m. on 6/7/11 revealed he did not have documented testing of the emergency light for the transfer switch in the boiler room on the preventive maintenance schedule. He stated he did not have a written schedule for the required monthly and yearly tests required for that device, but he tested it monthly.

Based on record review and interview, the provider failed to conduct quarterly fire drills for two of the three shifts during two of the four previous quarters for the 12 month period beginning June 2011. Findings include:

1. Fire drill record review revealed no documentation indicating fire drills had been conducted for the third shift (10 p.m.-6 a.m.) in the second quarter (April through June) of 2010 or the second shift (10 p.m.-6 a.m.) during the fourth quarter of 2010 (October through December). Interview with the plant operations supervisor at the time of the observation confirmed that finding. He stated the provider had been cited for the same issue during the 2011 survey for the attached nursing home since they held fire drills at the same time.

Based on observation and interview, the provider failed to furnish two means for transmitting the fire alarm system signal to an approved central station. The fire alarm systems communication device only had one phone line connected to it to signal the monitoring agency. A minimum of two means (two phone lines) for transmitting a signal offsite is required per NFPA 72, section 5-5.3.2.1.6.1. Findings include:

1. Observation at 1:38 p.m. revealed the fire alarm panel had a communication device with only one means for transmitting a signal off site (one telephone line) and not two as required by a digital alarm communicating transmitter (DACT). Interview with the plant operations supervisor at the time of the observation indicated he was not aware of the need for the second telephone line and would be getting a second line installed as soon as possible.

Based on observation and interview, the provider failed to maintain the width of corridors (clear and unobstructed) that served exit access by keeping a scale and a patient lift in the west patent sleeping wing corridor. Those items were kept in the corridor by staff for easy access. Findings include:

1. Observation at 3:08 p.m. revealed a fold-up scale and a patient lift were stored in the alcove at the end of the west patient sleeping wing corridor. Those items were placed, so they restricted the corridor width by 28 inches. Interview with the plant operations supervisor at the time of the observation confirmed that condition. The plant operations supervisor repositioned the patent lift and folded up the scale, so they would both fit into the alcove space and not impede the clear path of egress.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring and article 210-8 Ground-Fault Circuit-Interrupter Protection for Personnel. (See the above attachments.)

Based on observation and interview, the provider failed to furnish permanent wiring. Power strips were in-use in place of permanent wiring in the maintenance shop. Findings include:

1. Observation at 1:33 p.m. revealed a power strip in-use in place of permanent wiring in the maintenace shop. That power strip was used to power various items on the workbench as well as another power strip that was powering battery chargers for cordless power tools. Additionally the two incandecent lights placed on either side of the top of the workbench were wired using a lamp cord and barn style light fixtures. Interview with the plant operations supervisor at the time of the observation confirmed that condition. He stated that condition had existed as long as he could remember. He could not recall when those items had been placed into service.