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Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the corridor door leading to the remodel of the surgical suite area on the first floor. Findings include:

1. Observation at 11:00 a.m. on 10/4/11, revealed the temporary corridor door leading to the area of the surgical suite being remodeled was not provided with positive latching hardware. Interview with the director of plant operations at the time of the observation revealed the area was in a fire watch by both the contractor and the facility security. Because of the fire watch, the provider and contractor assumed sufficient fire protection was being maintained. The construction superintendent was informed of the requirement for positive latching doors and indicated a positive latch would be installed prior to the end of the contractor's shift.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area (soiled holding/utility room). The door to the soiled holding room was held in the open position by an unapproved device. Findings include:

1. Observation at 8:39 a.m. on 10/04/11 revealed the self-closing door to the soiled holding room located within the dialysis suite was held in the opened position with a rubber door wedge. That room had protection from the buildings automatic sprinkler system, but that door would not close to provide smoke separation to the rest of the suite. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated he regularly audited the campus for unapproved door holding devices and removed them when he found them. He further stated it was likely that rubber door wedge had been brought into the facility since his last audit.

Based on observation and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the corridor door leading to the remodel of the surgical suite area on the first floor. Findings include:

1. Observation at 11:00 a.m. on 10/4/11, revealed the temporary corridor door leading to the area of the surgical suite being remodeled was not provided with positive latching hardware. Interview with the director of plant operations at the time of the observation revealed the area was in a fire watch by both the contractor and the facility security. Because of the fire watch, the provider and contractor assumed sufficient fire protection was being maintained. The construction superintendent was informed of the requirement for positive latching doors and indicated a positive latch would be installed prior to the end of the contractor's shift.

Based on observation and interview, the provider failed to maintain proper separation of one randomly observed hazardous area (soiled holding/utility room). The door to the soiled holding room was held in the open position by an unapproved device. Findings include:

1. Observation at 8:39 a.m. on 10/04/11 revealed the self-closing door to the soiled holding room located within the dialysis suite was held in the opened position with a rubber door wedge. That room had protection from the buildings automatic sprinkler system, but that door would not close to provide smoke separation to the rest of the suite. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated he regularly audited the campus for unapproved door holding devices and removed them when he found them. He further stated it was likely that rubber door wedge had been brought into the facility since his last audit.