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Based on observation, interview, and record review, it was determined the Condition of Participation: Physical Plant and Environment was not met. The facility failed to maintain the physical environment to ensure the safety and well-being of patients. A life safety code survey initiated and concluded on 05/23/13, for compliance with Title 42, Code of Federal Regulations, §482.41(b) found the facility not to be in compliance with NFPA 101 Life Safety Code, 2000 Edition.

Refer to C231, K029, and K038.

Based observation, interview, and record review, it was determined the facility failed to meet the applicable provisions of NFPA 101, 2000 Edition, of the Life Safety Code. The facility failed to ensure that corridor doors to hazardous areas were maintained and equipped with door-closing devices as required and failed to maintain an exit according to NFPA standards.

Refer to K029 and K038.

The findings include:

1. During the Life Safety Code survey on 05/23/13 at 2:25 PM, with the Director of Maintenance (DOM), four corridor doors in the Radiology area were observed to not close correctly and would hang in the open position. These doors are required to close and latch on their own accord and remain closed. In addition, during the survey on 05/23/13, a Kitchen door was observed not to have a door-closing device.

An interview with the DOM on 05/23/13 at 2:25 PM revealed the doors were heavy and difficult to fix.

On 05/23/13 at 2:45 PM, hazardous area corridor doors to the Pharmacy were observed not to have self-closing devices as required. An interview with the DOM on 05/23/13 at 2:45 PM revealed she was not aware which doors were required to have self-closing devices. The facility was also issued a deficiency on 11/10/10 due to the failure to have door-closing devices on the Pharmacy doors.

2. During the Life Safety Code survey on 05/23/13 at 3:05 PM, with the Director of Maintenance (DOM) a cross-corridor door leading to the former Obstetrical (OB) clinic was observed to be locked with latches at the top of the doors. Storage was observed in the corridor of the clinic. These doors must remain unlocked due to egress requirements and storage is not allowed in the corridor. An interview with the DOM on 05/23/13 at 3:05 PM revealed the clinic was no longer in use and the area was being used for storage. The DOM was unaware the doors must remain unlocked and the clinic corridor cannot contain storage.