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Based on observation and interview, the provider failed to maintain the two hour fire-resistive separation between the hospital and attached nonconforming motel. Findings include:

1. Observation at 10:35 a.m. revealed the 90 minute fire rated cross-corridor doors separating the hospital from the attached motel would not latch into the frame when operated with the door closers. Interview with the director of plant operation at the time of the observation confirmed the doors closers would not fully close and latch those doors.

Based on observation and interview, the provider failed to maintain the smoke tight separation between the corridor and pain clinic suite. The corridor door was held in the open position by an unapproved device. Findings include:

1. Observation at 9:45 a.m. revealed the corridor door to the pain clinic suite on the second floor was held in the open position with a kick-down attached to the bottom of the door. The device would not allow the door to be closed with a single pulling motion on the door handle. Interview with the director of plan operations at the time of the observation confirmed the kick-down had to be placed in the upright position to allow the door to close.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The one hour fire rated doors to the third floor soiled utility room, trash room, and housekeeping storage would not positively latch into the frame. Findings include:

1. Observation between 10:45 a.m. and 11:15 a.m. revealed the one hour fire rated corridor doors to the third floor soiled utility room, trash chute room, and housekeeping storage room would not latch into the frames when allowed to operate with the door closers. Interview with the director of plant operation at the time of the observations confirmed the doors required closer adjustment to ensure positive latching.

Based on observation, testing, and interview, the provider failed to maintain the three hour horizontal exit doors in operating condition. Three of three pairs of cross-corridor horizontal exit doors would fully close and latch into the frames. Findings include:

1. Observations between 11:30 a.m. and 12:15 p.m. revealed the three hour cross-corridor horizontal exit doors separating the original construction from the addition would not close and latch with the door closers. Testing of the cross-corridor doors to pre-operative area, pediatric step-down area, and adult recovery area would not close and latch into the frames using the door closers. Interview with the director of plant operations at the time of the testing confirmed the doors needed adjustment.

Based on record review and interview, the provider failed to conduct the required number of monthly fire drills during the 2010 calendar year. Findings include:

1. Fire drill record review revealed no documentation indicating a fire drill had been conducted only on the day shift and only for the months of January, March, July, September, and December of 2010. Interview with the director of plan operations at the time of the record review revealed he thought if a fire drill was completed during each quarter the requirement was sufficiently met. It was explained to him because the facility operates on two twelve hours shifts monthly fire drills on alternating shifts was the requirement.

Based on observation and interview, the provider failed to maintain the two hour fire-resistive separation between the hospital and attached nonconforming motel. Findings include:

1. Observation at 10:35 a.m. revealed the 90 minute fire rated cross-corridor doors separating the hospital from the attached motel would not latch into the frame when operated with the door closers. Interview with the director of plant operation at the time of the observation confirmed the doors closers would not fully close and latch those doors.

Based on observation and interview, the provider failed to maintain the smoke tight separation between the corridor and pain clinic suite. The corridor door was held in the open position by an unapproved device. Findings include:

1. Observation at 9:45 a.m. revealed the corridor door to the pain clinic suite on the second floor was held in the open position with a kick-down attached to the bottom of the door. The device would not allow the door to be closed with a single pulling motion on the door handle. Interview with the director of plan operations at the time of the observation confirmed the kick-down had to be placed in the upright position to allow the door to close.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The one hour fire rated doors to the third floor soiled utility room, trash room, and housekeeping storage would not positively latch into the frame. Findings include:

1. Observation between 10:45 a.m. and 11:15 a.m. revealed the one hour fire rated corridor doors to the third floor soiled utility room, trash chute room, and housekeeping storage room would not latch into the frames when allowed to operate with the door closers. Interview with the director of plant operation at the time of the observations confirmed the doors required closer adjustment to ensure positive latching.

Based on observation, testing, and interview, the provider failed to maintain the three hour horizontal exit doors in operating condition. Three of three pairs of cross-corridor horizontal exit doors would fully close and latch into the frames. Findings include:

1. Observations between 11:30 a.m. and 12:15 p.m. revealed the three hour cross-corridor horizontal exit doors separating the original construction from the addition would not close and latch with the door closers. Testing of the cross-corridor doors to pre-operative area, pediatric step-down area, and adult recovery area would not close and latch into the frames using the door closers. Interview with the director of plant operations at the time of the testing confirmed the doors needed adjustment.

Based on record review and interview, the provider failed to conduct the required number of monthly fire drills during the 2010 calendar year. Findings include:

1. Fire drill record review revealed no documentation indicating a fire drill had been conducted only on the day shift and only for the months of January, March, July, September, and December of 2010. Interview with the director of plan operations at the time of the record review revealed he thought if a fire drill was completed during each quarter the requirement was sufficiently met. It was explained to him because the facility operates on two twelve hours shifts monthly fire drills on alternating shifts was the requirement.