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Based on observation, testing, and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and nursing home and hospital and clinic in three of three areas (door between soiled linen and laundry, penetration in wall between storage and community rehabilitation in the clinic, and the door between the clinic and hospital reception area). Findings include:

1. Observation, testing, and interview on 3/20/12 from 9:00 a.m. to 11:30 a.m. revealed:
a. The one hour rated self-closing metal door in the two hour wall between the soiled linen and laundry room would not close and latch when tested three out of four times. Interview with the maintenance supervisor (MS) at the time of the observation and testing confirmed that finding. He stated he was not aware that door would not always close and latch under the power of the self-closer. He stated he had a preventative maintenance (PM) plan to check corridor doors but had not checked the doors between the nursing home and hospital.
b. The two hour wall between the small storage room and the community rehabilitation in the clinic had a penetration from a communication cable. The penetrations were approximately the size of a softball and had not been sealed with fire caulk. Interview with the MS at the time of the observation and testing confirmed that finding. He stated he had thought their technology person had run new cables last fall. He had not thought about checking for penetrations after he was done.
c. The 90 minute rated self-closing door in the two hour wall between the clinic and the hospital reception area would not latch into the frame. Closer observation revealed the bolt mechanism was stuck inside the door and would not release. Interview with the MS at the time of the observation and testing confirmed that finding. He stated he was not aware the bolt mechanism for the door was stuck in the door. He stated he had a PM plan to check corridor doors but had not checked the doors between the clinic and hospital.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation on 3/20/12 at 9:00 a.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey conducted on 3/24/10 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

A. Based on record review and interview, the provider failed to conduct a night time fire drill for the first and second quarter of 2011. Findings include:

1. Review of the past fire drill records for 2011 and the first two months of 2012 revealed a night time fire drill had not been conducted for the first and second quarter of 2011. Interview with the maintenance supervisor (MS) at the time of the record review confirmed that finding. He stated the person who helped him with maintenance was in charge of conducting fire drills. He was not aware those night drills had not been conducted. The MS stated he had only started to report the status of the fire drills to quality assurance starting last fall and had missed the first two quarters of 2011.

B. Based on observation and interview, the provider failed to properly train all personnel involved in a fire drill. The two x-ray personnel did not implement and follow through with the proper procedures for a fire drill. Findings include:

1. Observation at 2:20 p.m. on 3/20/12 revealed the MS placed a sign with the following directions: "This Is A Fire Drill. Act as if this was a real fire. R = remove, A = alarm, C = contain, E = evacuate." on top of the desk in the x-ray office. The MS asked the x-ray manager and x-ray technologist (tech) to check the top of their desk when they returned from the x-ray room. The manager and tech could be heard reading the sign. After one minute had passed the surveyor asked what they should do about the sign. The x-ray manager asked if they were supposed to post the sign in the office or hallway. The MS then told them it was an actual fire drill, and they should act as if a fire was in the x-ray office. They then proceeded to close the door to the office, located and grabbed two extinguishers in the hallway, and then began to walk toward the nurses station. The MS then cued them on the next step, to announce the fire location. The tech then asked if she should pull the alarm. The MS told her to announce the location of the fire, and she pulled the alarm at that time. The two x-ray personnel then stood in the hallway by the x-ray office. The MS told them they needed to go to the nurses station to tell a nurse to announce the location of the fire.

Additional observation at the time of the fire drill revealed a patient had remained in the corridor by the nurses desk to watch the fire drill. He had not been removed to a secured area. Interview with the x-ray manager at the end of the drill revealed he and the tech had participated in several drills and thought he had done well.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building must be equipped with a complete automatic sprinkler system. Findings include:

1. Observation on 3/20/12 at 9:00 a.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey conducted on 3/24/10 confirmed that finding.

The building meets the FSES. Please mark and "F" in the completion date column (X5).

A. Based on record review and interview, the provider failed to ensure the automatic sprinkler system had required quarterly flow testing performed during the previous twelve months. Record review of the previous twelve months fire sprinkler system inspections revealed quarterly flow testing documentation was not available. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports revealed quarterly flow testing documentation was not available. Interview with the maintenance supervisor (MS) at the time of the record review confirmed that finding. He indicated he had been consulted by the inspecting company in August 2010 quarterly flow tests were needed, but he had not contacted them to conduct those tests.

B. Based on observation, measurement, and interview, the provider failed to maintain unobstructed space adjacent to the sprinkler deflector, so the water discharge was not interrupted. One randomly observed sprinkler in the central supply room was found obstructed. Findings include:

1. Observation at 11:00 a.m. on 3/20/12 revealed the sprinkler in the central supply room was obstructed by two identical cardboard boxes approximately 18 by 24 inches in size. Those boxes rested on the top shelf approximately six inches directly below the sprinkler head. Interview with the MS at the time of the observation confirmed that finding. He revealed he was not aware of the obstructed sprinkler but stated staff were aware sprinkler heads could not be obstructed. The MS removed the boxes at that time.

Based on observation and interview, the provider failed to ensure the safety of patients from possible burns and/or fire. Five portable space heaters were located in the south corridor leased to a dental clinic. Findings include:

1. Observation from 10:20 a.m. to 10:35 a.m. on 3/20/12 revealed four electric space heaters attached to the walls in the corridor, reception area, and break room. Those electric space heaters were not permanently wired and had been plugged into a local outlet on the wall. In addition an oil filled space heater was found in-use in the dentist's office. Interview with the maintenance supervisor at the time of the observations confirmed those findings. He stated the south corridor could not be kept warm by the old boiler unit that serviced the corridor. He stated he had installed those space heaters to keep the dental clinic staff and patients warmer. He revealed he was not aware those heaters were still considered space heaters as they were not permanently installed or wired into the facility. The MS stated he was not aware the dentist had brought in an outside space heater for use in his office. The MS was aware space heaters were not allowed in healthcare facilities.

Based on observation and interview, the provider failed to restrain three of three large (size H) portable oxygen cylinders in a secured position in the oxygen storage room. Findings include:

1. Observation at 11:20 a.m. on 3/20/12 revealed three size H unrestrained oxygen cylinders stored in the northwest corner of the oxygen storage room. Interview with the maintenance supervisor (MS) at the time of the observation confirmed that finding. He stated he was not aware who the three H tanks belonged to as all his L tanks were restrained. Continued interview with the MS at 1:45 p.m. on that same day revealed he had found out the three H size oxygen tanks belonged to the ambulance service. He stated he had restrained those tanks and informed the ambulance service their tanks must be restrained at all times in the oxygen storage room.

Based on observation, interview, and record review, the provider failed to install a paved path of exit discharge to the public way at one exit (south exit stair enclosure) of the building. Findings include:

1. Observation at 10:30 a.m. on 3/20/12 revealed the exit from the south exit stair enclosure had a landing that ended approximately 75 feet from the nearest street. Interview with the maintenance supervisor at the time of the observation confirmed that condition. The maintenance supervisor also stated he believed the facility had always been that way. Review of the previous survey conducted on 3/24/10 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and interview, the provider failed to install permanent wiring for the mental health counselor's office in the leased dental office corridor. Two extension cords were plugged into a power strip. Three power strips were plugged into a multiple tap adapter. An extension cord was found in-use for the computer speakers. Findings include:

1. Observation at 10:30 a.m. on 3/20/12 revealed two in-use extension cords were plugged into a power strip in the northeast corner of the office. Three power strips were found in-use and plugged into a multiple tap adapter over the electrical outlet. An extension cord was found in-use for the computer speakers. Interview with the maintenance supervisor (MS) at the time of the observation confirmed those findings. He said the counselor must have brought the devices from home. The MS stated he was not aware why the counselor would need all the outlets and removed the extension cords, extra power strips, and multiple tap adapter at that time.

Interview with the mental health counselor at 10:50 a.m. on that same day revealed he wanted to argue the fact that he needed those items to run games and videos during sessions. He revealed he was not aware those items were not allowed in healthcare facilities, but he was not a part of the healthcare facility. It was relayed to the counselor the surveyor from the South Dakota Department of Health had access to all areas of the healthcare facility when a complete separation was not present in the building between the hospital and the leased area of the clinic.