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Based on observation and interview, the facility failed to provide corridor protection in 1 of 4 wings. Failure to provide protection of the corridor puts all patients at risk should evacuation or movement be necessary. Census was 4.

Findings Are:

On 1/30/12 at 3:03 P.M., observation revealed the door for the linen closet would not close and latch tightly in its frame. Interview with Maintenance " A " verified the lack of latching of the door.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in the facility. The deficient practice could affect one of four smoke compartments, Patients, visitors and staff in the Zone. Census was 4.

Findings are:
Observation on 01-30-12 at 3:30 P.M. revealed the doors to the Cat-Scan room and the X-Ray room each have double doors with one being a small leaf. The small leaf has a manual latch which requires manual operation of it to close the door. During the inspection, neither small leaf was latched tightly in its frame. Interview with maintenance " A " confirmed the findings.

NFPA 101 18.2.3.5 requires that Hospital rooms used as diagnostic and x-ray shall have a clear width opening of 41 ? inch.
Exception # 4 allow for a pair of doors as long as one is at least 32 inches clear opening and the small leaf shall have an automatic flush bolt to provide positive latching.

Based on observation and interview, the facility failed to properly install alcohol based hand rub dispensers. This could affect all residents, visitors and staff in Zone 1 of 4. Census was 4.

Findings Are:

During the survey on 01-30-12 at 01:55 P.M., it was observed that the alcohol-based hand rub dispenser in the physical Therapy room was installed closer than the required 12 inch min. horizontal distance from an electrical switch which is an ignition source. During an interview on 01-30-12 at 01:55 P.M., Maintenance "A" Confirmed the deficient installation.

Based on observation and interview, the facility failed to provide corridor protection in 1 of 4 wings. Failure to provide protection of the corridor puts all patients at risk should evacuation or movement be necessary. Census was 4.

Findings Are:

On 1/30/12 at 3:03 P.M., observation revealed the door for the linen closet would not close and latch tightly in its frame. Interview with Maintenance " A " verified the lack of latching of the door.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in the facility. The deficient practice could affect one of four smoke compartments, Patients, visitors and staff in the Zone. Census was 4.

Findings are:
Observation on 01-30-12 at 3:30 P.M. revealed the doors to the Cat-Scan room and the X-Ray room each have double doors with one being a small leaf. The small leaf has a manual latch which requires manual operation of it to close the door. During the inspection, neither small leaf was latched tightly in its frame. Interview with maintenance " A " confirmed the findings.

NFPA 101 18.2.3.5 requires that Hospital rooms used as diagnostic and x-ray shall have a clear width opening of 41 ? inch.
Exception # 4 allow for a pair of doors as long as one is at least 32 inches clear opening and the small leaf shall have an automatic flush bolt to provide positive latching.