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Based on observation and interview, the facility utilized roller latches on 2 of 51 corridor doors (conference room and lobby) located in the facility. The failed practice had the potential to affect all patients, staff, and visitors and due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire event. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

A. On a tour of the facility with the Administrator on 07/09/13 at 1330 a roller latch was observed on the conference room door and the door separating the lobby and main corridor.
B. In an interview on 07/10/13 at 0920, the Maintenance Director verified the presence of the observed roller latches.

Based on observation and interview it was determined areas used to store combustible materials were not protected as hazardous areas due to a lack of fire rated construction or sprinklering of a storage room in the Outpatient Services department and the absence of a latch on the Soiled Holding Room door to maintain the door in the closed position. Storing the combustible materials in an unprotected room had the potential to affect all patients, staff and visitors due to the spread of fire and smoke from the room in the event of a fire. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

A. On a tour of the facility on 07/09/13 at 1330 with the Maintenance Director, the Soiled Holding Room was observed without a latch or handle to maintain the door in the closed position. The door was opened by pushing the door.
B. On a tour of the facility on 07/10/13 at 0930, a janitor ' s closet located in the Outpatient Services Department was used to store combustible materials in volume to be considered hazardous. The closet contained cardboard boxes of Styrofoam cups, five cardboard boxes of plastic dinnerware, and 3 cardboard boxes of snacks. The room was not protected by fire rated construction or sprinklering.
C. The lack of latching hardware on the Soiled Holding Room door was verified by interview with the Maintenance Director on 07/09/13 at 1350.
D. The unprotected storage of combustibles was verified by the Maintenance Director in an interview on 07/10/13 at 0945.

Based on observation and interview it was determined the facility did not maintain egress corridors free of obstructions to allow instantaneous use in the event of an emergency. The failed practice had the potential to affect all patient, staff, and visitors due to potential delay in emergency egress presented by the corridor obstructions. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

A. On a tour of the facility with the Administrator on 07/09/13 at 1300, the following unattended items were observed in the egress corridor of the facility:
1. Two wheelchairs, one infusion pump, and one vital sign monitor were by the X-Ray Office.
2. Two computer carts plugged into an electrical outlet between Patient Room 305 and the CT (Computerized Tomography) Exam Room.
3. One computer cart and two vital sign monitors were between the Galley and Patient Room 316.
4. One computer cart by Patient Room 317.
5. Two chairs by the Director of HIM (Health Information Management) office.
6. Two chairs outside the Physical Therapy office.
B. On 07/10/13 at 1045, the following unattended items were observed in the egress corridor of the facility:
1. Two wheelchairs and one vital signs monitor by the X-Ray Office.
2. Two chairs by the Director of HIM's office.
3. Two chairs outside the Physical Therapy office.
4. Two computer carts plugged into an electrical outlet were between Patient Room 305 and the CT Exam Room.
5. One computer cart and one vital sign monitor between the Galley and Patient Room 316.
6. One computer cart at the entrance to Outpatient Services near Patient Room 317.
C. In an interview conducted on 07/09/13 at 1350, the Maintenance Director verified the items located in the corridor.

Based on observation and interview, the facility utilized roller latches on 2 of 51 corridor doors (conference room and lobby) located in the facility. The failed practice had the potential to affect all patients, staff, and visitors and due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire event. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

A. On a tour of the facility with the Administrator on 07/09/13 at 1330 a roller latch was observed on the conference room door and the door separating the lobby and main corridor.
B. In an interview on 07/10/13 at 0920, the Maintenance Director verified the presence of the observed roller latches.

Based on observation and interview it was determined areas used to store combustible materials were not protected as hazardous areas due to a lack of fire rated construction or sprinklering of a storage room in the Outpatient Services department and the absence of a latch on the Soiled Holding Room door to maintain the door in the closed position. Storing the combustible materials in an unprotected room had the potential to affect all patients, staff and visitors due to the spread of fire and smoke from the room in the event of a fire. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

A. On a tour of the facility on 07/09/13 at 1330 with the Maintenance Director, the Soiled Holding Room was observed without a latch or handle to maintain the door in the closed position. The door was opened by pushing the door.
B. On a tour of the facility on 07/10/13 at 0930, a janitor ' s closet located in the Outpatient Services Department was used to store combustible materials in volume to be considered hazardous. The closet contained cardboard boxes of Styrofoam cups, five cardboard boxes of plastic dinnerware, and 3 cardboard boxes of snacks. The room was not protected by fire rated construction or sprinklering.
C. The lack of latching hardware on the Soiled Holding Room door was verified by interview with the Maintenance Director on 07/09/13 at 1350.
D. The unprotected storage of combustibles was verified by the Maintenance Director in an interview on 07/10/13 at 0945.

Based on observation and interview it was determined the facility did not maintain egress corridors free of obstructions to allow instantaneous use in the event of an emergency. The failed practice had the potential to affect all patient, staff, and visitors due to potential delay in emergency egress presented by the corridor obstructions. The facility had a census of zero in-patients on 07/08/13 and had an average monthly census of 15 patients. The findings follow:

A. On a tour of the facility with the Administrator on 07/09/13 at 1300, the following unattended items were observed in the egress corridor of the facility:
1. Two wheelchairs, one infusion pump, and one vital sign monitor were by the X-Ray Office.
2. Two computer carts plugged into an electrical outlet between Patient Room 305 and the CT (Computerized Tomography) Exam Room.
3. One computer cart and two vital sign monitors were between the Galley and Patient Room 316.
4. One computer cart by Patient Room 317.
5. Two chairs by the Director of HIM (Health Information Management) office.
6. Two chairs outside the Physical Therapy office.
B. On 07/10/13 at 1045, the following unattended items were observed in the egress corridor of the facility:
1. Two wheelchairs and one vital signs monitor by the X-Ray Office.
2. Two chairs by the Director of HIM's office.
3. Two chairs outside the Physical Therapy office.
4. Two computer carts plugged into an electrical outlet were between Patient Room 305 and the CT Exam Room.
5. One computer cart and one vital sign monitor between the Galley and Patient Room 316.
6. One computer cart at the entrance to Outpatient Services near Patient Room 317.
C. In an interview conducted on 07/09/13 at 1350, the Maintenance Director verified the items located in the corridor.