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Based on observation, testing, and interview, the pprovider failed to maintain the smoke tight rating of one corridor wall assembly for the bariatric room (108) door. The small leaf would not close and latch into the larger leaf of the door. Findings include:

1. Observation at 3:10 p.m. on 12/28/10 revealed two corridor doors for the bariatric room (108). Testing of those doors revealed the 12 inch leaf would not close tight to allow the 46 inch leaf to latch into that 12 inch leaf. Closer observation revealed the 12 inch leaf had self-closing hinges. Those hinges would not close the door from an open position. Interview with the environmental services supervisor (ESS) at the time of the observation and testing confirmed that finding. The ESS stated he was not aware those doors were not working correctly. He stated he had not had a chance to create a preventative maintenance (PM) checklist for the doors within the facility.

Based on observation, testing, and interview, the provider failed to maintain self-closing one hour rated smoke barrier doors on two sets of cross-corridor doors. Random observation revealed the east leaves of the smoke barrier doors by room 101 and between the lobby and educational corridor would not latch into the frame. Findings include:

1. Observation at 3:15 p.m. on 12/28/10 revealed a set of one hour rated smoke barrier doors by room 101. Upon release of the magnetic hold open devices the vertical rod of the east leaf would not latch into the striker plate on the top of the door frame. Interview with the ESS at the time of the observation and testing confirmed that condition. He stated he was not aware those doors were not working correctly. He stated he had not had a chance to create a preventative maintenance (PM) checklist for the doors within the facility.

2. Observation at 3:20 p.m. on 12/28/10 revealed a set of one hour rated smoke barrier doors between the lobby and the educational corridor. Upon release of the magnetic hold open devices the vertical rod of the east leaf would not latch into the striker plate on the top of the door frame. Interview with the ESS at the time of the observation and testing confirmed that condition. He stated he was not aware those doors were not working correctly. He stated he had not had a chance to create a PM checklist for the doors within the facility.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. Random observation revealed the one hour self-closing doors of the pharmacy storage room and materials storage room were held open with unapproved devices. Findings include:

1. Observation and testing at 2:20 p.m. on 12/28/10 revealed the one hour rated self-closing door to the pharmacy storage room was held open with a rubber wedge. That wedge created an impediment to closing that door. Interview with the environmental services supervisor (ESS) at the time of the observation confirmed that finding. Interview at that same time with the pharmacy assistant revealed she used that rubber wedge to hold the door open when she would move the medication cart from room-to-room within the pharmacy suite. The ESS removed the wedge at that time.

2. Observation and testing at 9:00 a.m. on 12/29/10 revealed the one hour rated self-closing door to the materials storage room was held open with a five gallon water bottle. That water bottle created an impediment to closing that door. Interview with the ESS at the time of the observation confirmed that finding. Interview at that same time with the materials management supervisor revealed she used that water bottle to prop open the door when she moved supplies in and out of the room.

Based on observation, testing, and interview, the provider failed to maintain 90 minute self-closing fire doors in operating condition. One set of randomly observed fire rated doors between the kitchen/dining room and educational corridor would not latch into the floor pins. Findings include:

1. Observation at 3:30 p.m. on 12/28/10 revealed a set of 90 minute self-closing fire rated doors between the kitchen/dining room and educational corridor. Testing of those doors revealed neither vertical rod would latch into the floor pins upon closing to maintain the 90 minute fire resistive rating. Interview with the environmental services supervisor (ESS) at the time of observation and testing revealed he was not aware those vertical rods were not long enough to latch into the floor pins. The ESS stated he had not had a chance to create a preventative maintenance checklist for the doors within the facility.

Based on observation and interview, the provider failed to maintain an exit door free of decoration that could create an impediment to full and instant use in an emergency. One randomly observed glass exit door in the x-ray suite was completely covered with black poster board masking the door. Findings include:

1. Observation at 4:25 p.m. on 12/28/10 revealed the glass exit door on the north side of the x-ray suite had been completely covered with black poster board. In addition the glass window next to the exit door had also been covered with black poster board. Interview with the environmental services supervisor (ESS) at the time of the observation confirmed that condition. The ESS stated he was aware the door had been covered with black poster board. Interview with the radiology manager at that same time revealed that door had been covered to darken the corridor for viewing of the imaging station. The ESS revealed he was not aware an exit door could not be covered or masked.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for one doors and one rolling curtain. Random observation revealed the administrative suite door would not close and latch. The rolling curtain for the corridor window of the therapy suite was blocked open. Findings include:

1. Observation at 3:50 p.m. on 12/28/10 revealed the corridor door to the administrative suite was open. Testing of that door revealed it would not close and latch in the frame. Continued observation revealed the door was warped and would hit below the striker plate. Interview with the ESS at the time of the testing and observation confirmed that condition. Interview with the administrative assistant at that time revealed that door had not closed for a long time, but she had not contacted maintenance. The ESS stated he had not had a chance to create a PM checklist for the doors within the facility.

2. Observation at 3:55 p.m. on 12/28/10 revealed the window sill below the rolling corridor curtain to the therapy suite was obstructed by a tissue box, a box of face masks, and a clip board laid on its edge against the wall. Interview with the ESS at the time of the observation confirmed that finding. The ESS stated he was aware those rolling curtains could not have obstructions to allow proper closing against the window sill. He stated he had not had a chance to create a PM checklist for the doors and rolling curtains within the facility.

Based on interview, the provider could not present a copy of a policy for what to do when the automatic sprinkler system was out of service for more then 4 hours in a 24 hour period. Findings include:

1. Interview with the environmental services supervisor (ESS) at 10:00 a.m. on 12/29/10 revealed he did not have a policy or procedure for the implementation of a plan when the automatic sprinkler system was out of service for more then 4 hours in a 24 hour period. The ESS stated he was aware there must be a policy but had not created one for the new facility.

Based on interview, the provider could not present a copy of a policy for what to do when the fire alarm system was out of service for more then 4 hours in a 24 hour period. Findings include:

1. Interview with the environmental services supervisor (ESS) at 10:00 a.m. on 12/29/10 revealed he did not have a policy or procedure for the implementation of a plan when the fire alarm system was out of service for more then 4 hours in a 24 hour period. The ESS stated he was aware there must be a policy but had not created one for the new facility.

Based on observation, testing, and interview, the pprovider failed to maintain the smoke tight rating of one corridor wall assembly for the bariatric room (108) door. The small leaf would not close and latch into the larger leaf of the door. Findings include:

1. Observation at 3:10 p.m. on 12/28/10 revealed two corridor doors for the bariatric room (108). Testing of those doors revealed the 12 inch leaf would not close tight to allow the 46 inch leaf to latch into that 12 inch leaf. Closer observation revealed the 12 inch leaf had self-closing hinges. Those hinges would not close the door from an open position. Interview with the environmental services supervisor (ESS) at the time of the observation and testing confirmed that finding. The ESS stated he was not aware those doors were not working correctly. He stated he had not had a chance to create a preventative maintenance (PM) checklist for the doors within the facility.

Based on observation, testing, and interview, the provider failed to maintain self-closing one hour rated smoke barrier doors on two sets of cross-corridor doors. Random observation revealed the east leaves of the smoke barrier doors by room 101 and between the lobby and educational corridor would not latch into the frame. Findings include:

1. Observation at 3:15 p.m. on 12/28/10 revealed a set of one hour rated smoke barrier doors by room 101. Upon release of the magnetic hold open devices the vertical rod of the east leaf would not latch into the striker plate on the top of the door frame. Interview with the ESS at the time of the observation and testing confirmed that condition. He stated he was not aware those doors were not working correctly. He stated he had not had a chance to create a preventative maintenance (PM) checklist for the doors within the facility.

2. Observation at 3:20 p.m. on 12/28/10 revealed a set of one hour rated smoke barrier doors between the lobby and the educational corridor. Upon release of the magnetic hold open devices the vertical rod of the east leaf would not latch into the striker plate on the top of the door frame. Interview with the ESS at the time of the observation and testing confirmed that condition. He stated he was not aware those doors were not working correctly. He stated he had not had a chance to create a PM checklist for the doors within the facility.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. Random observation revealed the one hour self-closing doors of the pharmacy storage room and materials storage room were held open with unapproved devices. Findings include:

1. Observation and testing at 2:20 p.m. on 12/28/10 revealed the one hour rated self-closing door to the pharmacy storage room was held open with a rubber wedge. That wedge created an impediment to closing that door. Interview with the environmental services supervisor (ESS) at the time of the observation confirmed that finding. Interview at that same time with the pharmacy assistant revealed she used that rubber wedge to hold the door open when she would move the medication cart from room-to-room within the pharmacy suite. The ESS removed the wedge at that time.

2. Observation and testing at 9:00 a.m. on 12/29/10 revealed the one hour rated self-closing door to the materials storage room was held open with a five gallon water bottle. That water bottle created an impediment to closing that door. Interview with the ESS at the time of the observation confirmed that finding. Interview at that same time with the materials management supervisor revealed she used that water bottle to prop open the door when she moved supplies in and out of the room.

Based on observation, testing, and interview, the provider failed to maintain 90 minute self-closing fire doors in operating condition. One set of randomly observed fire rated doors between the kitchen/dining room and educational corridor would not latch into the floor pins. Findings include:

1. Observation at 3:30 p.m. on 12/28/10 revealed a set of 90 minute self-closing fire rated doors between the kitchen/dining room and educational corridor. Testing of those doors revealed neither vertical rod would latch into the floor pins upon closing to maintain the 90 minute fire resistive rating. Interview with the environmental services supervisor (ESS) at the time of observation and testing revealed he was not aware those vertical rods were not long enough to latch into the floor pins. The ESS stated he had not had a chance to create a preventative maintenance checklist for the doors within the facility.

Based on observation and interview, the provider failed to maintain an exit door free of decoration that could create an impediment to full and instant use in an emergency. One randomly observed glass exit door in the x-ray suite was completely covered with black poster board masking the door. Findings include:

1. Observation at 4:25 p.m. on 12/28/10 revealed the glass exit door on the north side of the x-ray suite had been completely covered with black poster board. In addition the glass window next to the exit door had also been covered with black poster board. Interview with the environmental services supervisor (ESS) at the time of the observation confirmed that condition. The ESS stated he was aware the door had been covered with black poster board. Interview with the radiology manager at that same time revealed that door had been covered to darken the corridor for viewing of the imaging station. The ESS revealed he was not aware an exit door could not be covered or masked.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for one doors and one rolling curtain. Random observation revealed the administrative suite door would not close and latch. The rolling curtain for the corridor window of the therapy suite was blocked open. Findings include:

1. Observation at 3:50 p.m. on 12/28/10 revealed the corridor door to the administrative suite was open. Testing of that door revealed it would not close and latch in the frame. Continued observation revealed the door was warped and would hit below the striker plate. Interview with the ESS at the time of the testing and observation confirmed that condition. Interview with the administrative assistant at that time revealed that door had not closed for a long time, but she had not contacted maintenance. The ESS stated he had not had a chance to create a PM checklist for the doors within the facility.

2. Observation at 3:55 p.m. on 12/28/10 revealed the window sill below the rolling corridor curtain to the therapy suite was obstructed by a tissue box, a box of face masks, and a clip board laid on its edge against the wall. Interview with the ESS at the time of the observation confirmed that finding. The ESS stated he was aware those rolling curtains could not have obstructions to allow proper closing against the window sill. He stated he had not had a chance to create a PM checklist for the doors and rolling curtains within the facility.

Based on interview, the provider could not present a copy of a policy for what to do when the automatic sprinkler system was out of service for more then 4 hours in a 24 hour period. Findings include:

1. Interview with the environmental services supervisor (ESS) at 10:00 a.m. on 12/29/10 revealed he did not have a policy or procedure for the implementation of a plan when the automatic sprinkler system was out of service for more then 4 hours in a 24 hour period. The ESS stated he was aware there must be a policy but had not created one for the new facility.

Based on interview, the provider could not present a copy of a policy for what to do when the fire alarm system was out of service for more then 4 hours in a 24 hour period. Findings include:

1. Interview with the environmental services supervisor (ESS) at 10:00 a.m. on 12/29/10 revealed he did not have a policy or procedure for the implementation of a plan when the fire alarm system was out of service for more then 4 hours in a 24 hour period. The ESS stated he was aware there must be a policy but had not created one for the new facility.