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Based on observation and interview it was determined the half hour fire resistance rating of corridor walls was compromised by an unprotected opening around a pipe penetration of the wall at one of three locations inspected. Failure to maintain the fire resistance rating has the potential to affect the health and safety of all patients due to the potential of fire and smoke transfer between the corridor and patient rooms. The facility had a census of 23 psychiatric patients on 11/15/11. The findings follow:

A. On a tour of the facility on 11/16/11 at 1250 with the Director of Plant Operations/Maintenance, a pipe penetration was observed above the ceiling at the smoke barrier doors located at the nurse station on the fifth (5th) floor nursing unit. A section of the wall around the pipe was missing, allowing a clear opening between the corridor and patient room sides of the corridor wall, thus compromising the half fire resistance rating of the corridor wall.
B. In an interview with on 11/16/11 at 1430, the Director of Plant Operations/Maintenance verified the location of the hole in the corridor wall on the fifth (5th) floor nursing unit.

Based on observation and interview, six of six patient room doors on the Acute Care Unit had roller latches. The roller latches had the potential to affect the health and safety of all patients due to the failure of roller latches to maintain the doors in the closed position in the event of a fire and smoke event. The findings follow:

A. On a tour of the facility with the Administrator, Director of Nursing, and Chief Financial Officer on 12/2/11 at 1000, roller latches were observed on six of six patient room doors on the third floor Acute Care Unit. Roller latches were observed on Rooms #304, #306, #307, #308, #309, and #310.
B. The Administrator confirmed roller latches were provided on these patient rooms doors in an interview on 12/2/11 at 1015.

Based on observation and interview, it was determined the facility was utilizing an unprotected patient room to store flammable materials on the third floor Acute Care Unit. The failed practice had the potential to affect the health and safety of all patients because the room was not provided with the required fire protection to prevent the spread of fire and smoke from the room. The findings follow:

A. On a tour of the facility on 12/2/11 at 1000 with the Administrator, Nurse Executive, and Chief Financial Officer, the following observations were made in Patient Room 307:
1) Patient Room 307 contained no patient accommodations or bed. The room contained shelving with multiple cardboard boxes. Multiple cardboard boxes were also on the floor. Signagel and flammable decorations were also located in the room. Two cardboard boxes of liquor were on the floor.
2) The entire third floor was unsprinklered, including Patient Room 307. The door to Patient Room 307 was not fire rated and was not provided with a closing device. The room was not separated from the remainder of the building with fire rated construction.
B. In an interview conducted on 12/2/11 at 1020 the Administrator stated the facility intended to turn the room back into a patient room. He verified the room contained flammable materials.

Based on observation and interview it was determined the half hour fire resistance rating of corridor walls was compromised by an unprotected opening around a pipe penetration of the wall at one of three locations inspected. Failure to maintain the fire resistance rating has the potential to affect the health and safety of all patients due to the potential of fire and smoke transfer between the corridor and patient rooms. The facility had a census of 23 psychiatric patients on 11/15/11. The findings follow:

A. On a tour of the facility on 11/16/11 at 1250 with the Director of Plant Operations/Maintenance, a pipe penetration was observed above the ceiling at the smoke barrier doors located at the nurse station on the fifth (5th) floor nursing unit. A section of the wall around the pipe was missing, allowing a clear opening between the corridor and patient room sides of the corridor wall, thus compromising the half fire resistance rating of the corridor wall.
B. In an interview with on 11/16/11 at 1430, the Director of Plant Operations/Maintenance verified the location of the hole in the corridor wall on the fifth (5th) floor nursing unit.

Based on observation and interview, six of six patient room doors on the Acute Care Unit had roller latches. The roller latches had the potential to affect the health and safety of all patients due to the failure of roller latches to maintain the doors in the closed position in the event of a fire and smoke event. The findings follow:

A. On a tour of the facility with the Administrator, Director of Nursing, and Chief Financial Officer on 12/2/11 at 1000, roller latches were observed on six of six patient room doors on the third floor Acute Care Unit. Roller latches were observed on Rooms #304, #306, #307, #308, #309, and #310.
B. The Administrator confirmed roller latches were provided on these patient rooms doors in an interview on 12/2/11 at 1015.

Based on observation and interview, it was determined the facility was utilizing an unprotected patient room to store flammable materials on the third floor Acute Care Unit. The failed practice had the potential to affect the health and safety of all patients because the room was not provided with the required fire protection to prevent the spread of fire and smoke from the room. The findings follow:

A. On a tour of the facility on 12/2/11 at 1000 with the Administrator, Nurse Executive, and Chief Financial Officer, the following observations were made in Patient Room 307:
1) Patient Room 307 contained no patient accommodations or bed. The room contained shelving with multiple cardboard boxes. Multiple cardboard boxes were also on the floor. Signagel and flammable decorations were also located in the room. Two cardboard boxes of liquor were on the floor.
2) The entire third floor was unsprinklered, including Patient Room 307. The door to Patient Room 307 was not fire rated and was not provided with a closing device. The room was not separated from the remainder of the building with fire rated construction.
B. In an interview conducted on 12/2/11 at 1020 the Administrator stated the facility intended to turn the room back into a patient room. He verified the room contained flammable materials.