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Based on observation and interview, the facility failed to maintain the integrity of corridor walls in accordance with 19.3.6.2.1 for a separation between a hazardous area electrical room and an adjacent corridor which serves as a protected egress to a designated exit. The facility census was 358.

Findings included:

1. Observations on 06/5/13 at 4:20 PM showed a three inch hole penetrated the concrete block wall of an electrical room identified as "1st Floor, Substation 7."

During an interview on 06/05/13 at 04:25 PM, Staff JJJ acknowledged the observation and stated that workers make regular monthly preventive maintenance rounds through the floors and associated areas. He stated that he was not sure if the hole was new or if they had just failed to observe it during their rounds.

Based on observation and interview, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and the facility census of 358 patients.

Findings included:

1. Observation on 06/5/13 at 3:00 PM in the 6100 wing showed the doors to two patient rooms, 6106 and 6134, failed to latch when closed into the jamb. The latch bolts of both doors appeared to be jammed or seized, which prevented the bolt from engaging the strike plate.

During an interview on 06/5/13 at 3:00 PM, Staff JJJ, Director of Building Services acknowledged the finding and called the building's locksmith. He stated that maintenance workers check door functions on regular monthly Preventive Maintenance rounds, but may not check every patient room door each month.

Based on observation, the facility failed to ensure a clear path of egress to an exit in accordance with 7.1.10.1 and 19.2.3.3; through an exit corridor outside of, and at the at the southwest end of the Emergency Department (ED). This deficient practice potentially affects all patients, staff and visitors in the vicinity of the ED. The facility census was 358.

Findings included:

1. Observation on 06/04/13 at 11:00 AM showed a total of nine hospital beds parked in the corridor outside of the southwest end of the Emergency Department. Four beds were arranged along one wall of a in the 50 foot end section, two more beds were in the corridor area on the northwest side, and three beds were parked in the corridor on the southeast side of the corridor. The latter three beds were positioned across the corridor from each other, and further restricted the corridor width to less than four feet. The corridors served a 59 bed ED, ultrasound test/exam rooms, visitor waiting area and an endoscopy suite.

During an interview on 06/4/13 at 11:00 AM, Staff JJJ, Director of Building Services acknowledged the finding and stated he did not know where the beds came from or why the beds were parked in the corridor.

Based on observation and interview, the facility failed to maintain the integrity of corridor walls in accordance with 19.3.6.2.1 for a separation between a hazardous area electrical room and an adjacent corridor which serves as a protected egress to a designated exit. The facility census was 358.

Findings included:

1. Observations on 06/5/13 at 4:20 PM showed a three inch hole penetrated the concrete block wall of an electrical room identified as "1st Floor, Substation 7."

During an interview on 06/05/13 at 04:25 PM, Staff JJJ acknowledged the observation and stated that workers make regular monthly preventive maintenance rounds through the floors and associated areas. He stated that he was not sure if the hole was new or if they had just failed to observe it during their rounds.

Based on observation and interview, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and the facility census of 358 patients.

Findings included:

1. Observation on 06/5/13 at 3:00 PM in the 6100 wing showed the doors to two patient rooms, 6106 and 6134, failed to latch when closed into the jamb. The latch bolts of both doors appeared to be jammed or seized, which prevented the bolt from engaging the strike plate.

During an interview on 06/5/13 at 3:00 PM, Staff JJJ, Director of Building Services acknowledged the finding and called the building's locksmith. He stated that maintenance workers check door functions on regular monthly Preventive Maintenance rounds, but may not check every patient room door each month.

Based on observation, the facility failed to ensure a clear path of egress to an exit in accordance with 7.1.10.1 and 19.2.3.3; through an exit corridor outside of, and at the at the southwest end of the Emergency Department (ED). This deficient practice potentially affects all patients, staff and visitors in the vicinity of the ED. The facility census was 358.

Findings included:

1. Observation on 06/04/13 at 11:00 AM showed a total of nine hospital beds parked in the corridor outside of the southwest end of the Emergency Department. Four beds were arranged along one wall of a in the 50 foot end section, two more beds were in the corridor area on the northwest side, and three beds were parked in the corridor on the southeast side of the corridor. The latter three beds were positioned across the corridor from each other, and further restricted the corridor width to less than four feet. The corridors served a 59 bed ED, ultrasound test/exam rooms, visitor waiting area and an endoscopy suite.

During an interview on 06/4/13 at 11:00 AM, Staff JJJ, Director of Building Services acknowledged the finding and stated he did not know where the beds came from or why the beds were parked in the corridor.