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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 and the waiting room. Findings include:

1. Observation at 11:59 a.m. on 5/17/11 revealed an accordion style door was the only separation between the business office and the exit corridor system. Further observation revealed the business office was not equipped with smoke detector protection from the automatic fire alarm system. 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.

2. Observation at 12:05 a.m. on 5/17/11 revealed no separation was provided between the waiting room and the exit corridor system. Further observation revealed the waiting room was not equipped with smoke detector protection from the automatic fire alarm system. 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.

A. Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the east wing. One randomly observed door to the corridor (exam room four) would not close and latch. Findings include:

1. Observation and testing at 12:13 p.m. revealed the corridor door leading from exam room four would not latch into the door frame upon closing when tested. Interview with the maintenance director at the time of the observation confirmed that condition.

B. Based on observation, testing, and interview, the provider failed to furnish latching hardware for two doors (the pantry near the nurses station and the small storage room near the nursery). Findings include:

1. Observation and testing beginning at 12:21 p.m. and ending at 12:59 p.m. revealed the corridor door to the pantry area near the nurses station was not flurnished with latching hardware to latch into the door frame upon closing. That same condition was found at the corridor door to the small storage room near the nursery. Interview with the maintenance director at the time of the observations confirmed those conditions.

Based on observation and interview, the provider failed to maintain self-closing smoke barrier doors. Two randomly observed cross-corridor doors in two smoke barrier walls (both the north and south wings) would not self-close and form a smoke tight seal. Findings include:

1. Observation at 12:28 p.m. revealed a set of doors in the smoke barrier wall between the south patient wing and the central smoke compartment would not close and form a smoke tight seal. When closed those doors left a gap that vairied from 1/2 inch to 3/8 inch. That gap was more than the allowed 1/8 inch. Interview with the maintenance director at the time of the observation confirmed that finding. He stated he was not aware those doors did not meet the requirement.

2. Observation at 1:48 p.m. revealed a set of doors in the smoke barrier wall between the north patient wing and the central smoke compartment would not close and form a smoke tight seal. When closed those doors left a gap that vairied from 1/2 inch to 3/8 inch. That gap was more than the allowed 1/8 inch. Interview with the maintenance director at the time of the observation confirmed that finding. He stated he was not aware those doors did not meet the requirement.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas for the one randomly observed combustible storage room. Findings include:

1. Observation at 12:10 p.m. revealed a storage area had been created by placing a glass and aluminum partition thru the center of the waiting room. Further observation revealed that storage room was used to store combustible items. Measurement revealed that combustible storage area was 167 square feet in size. That combustible storage room was larger than 50 square feet and was not separated from the buildings exit corridor system by a 1 hour fire rated enclosure. That combustible storage room also was not protected by the buildings automatic fire sprinkler system. Interview with the maintenance director at the time of observation confirmed those findings. He stated he was not aware combustible items were not allowed to be stored in that area.

Based on observation and interview, the provider failed to ensure exits were readily accessible at all times. Two doors (exam room two and exam room three) were provided with double-action hardware. Findings include:

1. Observation and interview at 3:00 p.m. revealed the corridor doors to both exam room two and exam room three had double-action hardware. Those doors were equipped with sliding barrel-bolt locks mounted at the top of the doors. Those sliding barrel-bolt locks created a condition where two actions had to be performed to leave those rooms. That double-action hardware would impede opening of those doors in an emergency. Interview with the maintenance director at the time of the observation revealed the barrel-bolt locks were likely installed for privacy because the doorknobs for those rooms were not equiped with a lock.

Based on observation and interview, the provider failed to install the required fire alarm system in accordance with NFPA 72 The National Fire Alarm Code. Smoke detection was not provided at every smoke barrier as required in existing non-sprinklered facilities. Findings include:

1. Observation at 1:30 p.m. revealed corridor smoke detection was only provided at the north smoke barrier wall, the south smoke barrier wall, the cafeteria smoke partition and at the separation between the hospital and the nursing home. Smoke detection was not provided on either side of the smoke barrier wall outside of exam room one or the smoke barrier wall outside the dictation room west of the nurses station. Interview with the maintenance director at the time of the observation confirmed that condition. He confirmed there were only four area smoke detectors in the building located at north smoke barrier wall, the south smoke barrier wall, the cafeteria smoke partition and at the separation between the hospital and the nursing home.

Based on observation and interview, the provider failed to perform monthly checks of all fire extinguishers in accordance with NFPA 10. Monthly checks had not been performed on one randomly observed fire extinguisher (medical records room) for April 2011. Findings include:

1. Random observation at 2:26 p.m. revealed the fire extinguisher in the medical records room did not have monthly maintenance performed in April 2011. Interview with the maintenance director at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) dispensers at two randomly observed rooms (exam room four and the doctors lounge). Findings include:

1. Observation beginning at 12:14 p.m. and ending at 1:50 p.m. revealed ABHR dispensers were installed adjacent to an electrical source in the exam room four and the doctors lounge. Interview at the time of the observation with the maintenance director confirmed that finding. He stated he belived most of the patient rooms would also have that same condition. He further stated he would relocate the ABHR dispensers to acceptable locations as soon as possible.