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Based on observation and interview, the provider failed to maintain corridor separation from use areas by walls with at least a 30 minute fire resistance rating at the business office. Findings include:

1. Observation at 2:52 p.m. revealed a pocket style sliding door was the only separation between the business office and the exit corridor system. Further observation revealed the business office was not equipped with a smoke detector. Interview with the maintenance director at the time of observation confirmed those findings. He stated that condition had existed as long as he had been employed at the facility (approximately 20 years).

A. Based on observation and interview, the provider failed to maintain the 20 minute fire resistive rating of corridor doors. Two randomly observed corridor doors (doctor's office and radiation changing room) were held in the open position by an unapproved device. Findings include:

1. Observation at 1:30 p.m. revealed the corridor door to the doctor's office was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

2. Observation at 1:30 p.m. revealed the corridor door to the radiation changing room was held in the open position with a rubber wedge. That device was an impediment to closing the door in an emergency. Interview with the maintenance supervisor at the time of the observation confirmed that condition.


B. Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the east wing. Two randomly observed doors (utility room and intravenous [IV] stand storage room) to the corridor would not close and latch. Findings include:

1. Observation and testing at 11:59 a.m. revealed the door from the utility room to the corridor would not latch into the door frame upon closing when tested. That door had originally been set-up as a bathroom that could be entered from the corridor in the event of an emergency. Originally that door had been equipped with a hinged door stop that would not allow the door to normally swing out. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

2. Observation and testing at 11:59 a.m. revealed the door from the IV stand storagfe room to the corridor would not latch into the door frame upon closing when tested. That door had originally been set-up as a bathroom that could be entered from the corridor in the event of an emergency. Originally that door had been equipped with a hinged door stop that would not allow the door to normally swing out. Interview with the maintenance supervisor at the time of the observation confirmed that condition.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas in two randomly observed locations (lab/X-ray film storage room and the record storage room and the human resource managers office ). Those doors would not close and latch into their respective frames. Findings include:

1. Observation and testing at 2:57 p.m. revealed the self-closing corridor door in the west wall of the lab/X-ray film storage room would not close and latch into the frame on three of three attempts. Further observation and testing revealed the latching mechanism of the door was sticking and would not travel far enough to latch. Interview with the maintenance supervisor at the time of the observation confirmed that finding. The maintenance supervisor stated he had not noticed that door was not properly latching.

2. Observation and testing at 3:19 p.m. revealed the self-closing door between the record storage room and the human resource managers office would not close and latch into the frame on three of three attempts. Further observation and testing revealed the latching mechanism of the door would hit the strike plate of the door frame but would not travel far enough to latch. Interview with the maintenance supervisor at the time of the observation confirmed that finding. The maintenance supervisor stated he had not noticed that door was not properly latching.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. One randomly observed door (kitchen) had been provided with double-action latching hardware. Findings include:

1. Observation and interview at 10:59 a.m. revealed the door from the kitchen to the service wing corridor had been equipped with a deadbolt. That deadbolt did not unlock with the actuation of the doorknob and could impede opening of that door in a fire emergency. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Based on observation and previous survey review, the provider failed to maintain at least two exits from the suite of patient rooms. Findings include:

1. Observation at 1:05 p.m. revealed only one exit was provided from the suite of patient rooms adjacent to the nurses station. Review of the documentation from the previous survey confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation and interview, the provider failed to ensure one randomly observed staff person was familiar with fire drill procedures. Findings include:

1. Observation during the fire drill at 9:20 a.m. revealed the central supply staff person responding to the simulated fire did not pull the fire alarm manual pull station to alert other staff to the fire condition. Additionally the human resource manager had to be instructed by the maintenance supervisor to go and activate the fire alarm with a manual pull station one minute after the drill had commenced. Interview with the plant maintenance supervisor at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The Type II (111) building had a portion of an interior wall constructed of combustible materials. Findings include:

1. Observation and interview on 10/7/11 at 11:25 p.m. revealed the building was a single-story, noncombustible, Type II (111) structure without a complete automatic sprinkler system. The building had a non-rated combustible wood panel used as a door that allowed access to the wall between the medical record storage room and the handicapped accessible shower. The wood panel that covered that wall penetration was not a noncombustible or limited combustible material, and therefore was an unacceptable construction material. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Based on document review and interview, the provider failed to conduct required weekly inspections for the emergency generator for the previous three years (2008-2011). Findings include:

1. Review of the generator log at 9:38 a.m. revealed the monthly emergency generator load runs were being documented as running for a minimum of 30 minutes with an additional five minutes of cool down time, but the log did not show evidence of weekly inspections for the previous three years (2008-2011). Interview with the maintenance supervisor at the time of the observation revealed he was unaware of the requirement for weekly inspections.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring. (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 one randomly observed location (intravenous [IV] stand storage room). Findings include:

1. Observation at 10:40 a.m. revealed a power strip in-use in place of permanent wiring in the IV stand storage room. That power strip was used to power two IV stands. Interview with the maintenance supervisor at the time of the observation confirmed that condition.