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Based on observation and interview, the provider failed to maintain two pairs of cross-corridor doors a (adjacent to the pharmacy and adjacent to patient room 109) as required. Findings include:

1. Observation on 8/22/23 at 10:15 a.m. revealed the cross corridor doors adjacent to the pharmacy could not fully close. The cross-corridor doors were held open with magnets tied into the fire alarm system. However, the doors could not fully close. There was a possibility that was caused by summer swelling of the doors, or it might have been because of installed edge protection.

2. Observation on 8/22/23 at 11:30 a.m. revealed the cross-corridor doors adjacent to patient room 109 could not fully close. The cross-corridor doors were held open with magnets tied into the fire alarm system. The closure problem was due to a non-functioning coordinator.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiencies affected one of numerous requirements for self-closing doors and had the potential to affect 100% of the occupants of the smoke compartments.

Based on observation and interview, the provider failed to maintain at least two conforming exits from the basement. Findings include:

1. Observation 8/22/23 at 11:45 a.m. revealed the basement was not provided with two approved means of egress. The basement boiler room was approximately 35 feet by 20 feet (700 square feet). The second exit discharged through the crawl space.

The building meets the FSES. Please mark an F in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

The deficiency would not affect any of the patients and only minimal staff.

Based on record review, observation, and interview, the facility failed to provide a maintenance plan for piped medical gases as required. Findings include:

1. Record review on 8/22/23 at 1:30 p.m. revealed a plan to provide medical gas outlet and system maintenance was not available. Interview with the maintenance director during the facility tour revealed no planning for maintenance or repair was available.

The deficiency could impact any patients within the hospital.