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Based on observation, document review, and interview, the provider failed to maintain proper separation of hazardous areas in two randomly observed areas (elevator hydraulic room and medical records storage room). The elevator hydraulic room in the lower level was a hazardous room without a sprinkler or a door closer. The medical records storage room was not equipped with a sprinkler. Findings include:

1. Observation at 10:45 a.m. on 7/22/14 revealed the elevator hydraulic room had a solid bonded wood core (SBWC) door without a label indicating its fire-resistive rating (an SBWC door has an equivalent to a 20 minute fire-rated door) without a closer. The corridor door was also an SBWC door without a label indicating its fire-resistive rating and was not equipped with a closer. Review of the NAPA (brand) hydraulic fluid specification documentation revealed the hydraulic fluid had a flash point of 375 degrees Fahrenheit. The room was considered to be a hazardous room requiring a sprinkler and a door closer or a one-hour fire-rated enclosure with a minimum 45 minute fire-rated door with a closer.

The plant operations director acknowledged the finding when the deficiency was identified.

Failure to maintain hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous rooms required to be protected as a hazardous area.

2. Observation at 1:15 p.m. on 7/22/14 revealed the medical records storage room was not equipped with either a sprinkler or a fire-rated door (one of the two is required). The room was over 100 square feet in area and contained a quantity of combustible paper records files.

The plant operations director acknowledged the finding when the deficiency was identified.

Failure to maintain hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous rooms required to be protected as a hazardous area.

Based on observation and interview, the provider failed to install a remote stop button for the generator. Findings include:

1. Observation at 10:45 a.m. on 7/22/14 revealed the generator providing power for emergency lighting was found to be lacking a remote manual stop station as required. That should have been mounted outside of the all-weather enclosure when the prime mover was located outside of the building.

Interview with the plant operations director at the time of the observation revealed he was unaware of the remote stop requirement for the generator.

The deficiency affected a single location required to be equipped with remote emergency stops.

Based on observation and interview, the provider failed to maintain proper separation of one of one soiled linen holding rooms. The soiled linen holding room was used for holding bagged soiled linen overnight in containers over 32 gallons in capacity and was not provided with either one hour fire-rated construction or automatic sprinkler protection. Findings include:

1. Observation at 1:15 p.m. on 7/22/14 revealed the soiled linen holding room was approximately 100 square feet in area and was used to hold bagged soiled linens for several consecutive nights until picked up. Two Rubbermaid (brand) wheeled carts were used for holding the soiled linens in the room (the large cart was 12 cubic feet, approximately 88 gallons; the small cart was approximately 32 gallons in capacity). The room was equipped with a solid bonded wood core door but was not provided with automatic sprinkler protection.

Interview with the plant operations director at the time of the observation revealed the soiled linens were sent to an out-of-town laundry service three times per week (Monday, Wednesday, and Friday).

The deficiency affected a single location required to be protected as a hazardous area for the storage of soiled linens.