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Based on observation, testing, and interview, the provider failed to maintain the two hour fire separation between the hospital and attached medical office building. One of three 90 minute fire rated doors connecting the building was held in the open position with a metal door wedge. Findings include:

1. Observation and testing at 9:30 a.m. revealed the 90 minute fire rated separation door between the hospital (recovery care two) and the medical office building was held in the open position with a spring steel device placed under the door. Testing of the door following removal of the device revealed the door did operate properly. The device was immediately removed and discarded. Interview with the maintenance supervisor at the time of that observation indicated he was unaware why that door needed to be held open.

Discussion with both the maintenance director and administrator during the exit conference indicated that if the door needed to be left open during the business hours of the medical office building a magnetic hold-open device connected to both the hospitals and medical office buildings fire alarms would be required.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas. The doors to both the soiled linen and clean linen rooms would not latch into the frame with the operation of the closer. Findings include:

1. Observation and testing at 11:00 a.m. revealed the self-closing door to the soiled linen room and the clean linen room in recovery care one would not close and latch into the frames. Further observation and testing revealed the doors were binding on the smoke seal along the hinge side of the doors. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He revealed he had checked the doors during the previous monthly fire safety evaluation, and the doors operated properly at that time.