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Based on observation and staff interview, it was determined that the facility failed to properly maintain the sprinkler system as required. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the Life Safety Survey tour of the facility at 1:40 pm on June 19, 2012 with the Maintenance Director, it was noticed that there were dirty sprinkler heads on the first floor Laboratory.

During the Staff Interview at 1:41 pm on June 19, 2012, the Maintenance Director stated the dirty sprinkler heads would be cleaned immediately.

NFPA 101 Life Safety Code (2000)
NFPA 13
NFPA 25

Based on record review and staff interview, it was determined that the facility failed to properly maintain the cooking hood fire suppression system as required. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the records review process of the facility between 10:00 am and 1:00 pm on June 19, 2012 with the Maintenance Director, it was noticed that there was no documentation for the cooking hood fire suppression system maintenance inspection for 2012 as required.

During the Staff Interview between 10:01 am and 1:01 pm on June 19, 2012, the Maintenance Director acknowledged that there was no documentation for the cooking hood fire suppression system maintenance inspection for 2012 as required.

NFPA 101 Life Safety Code (2000)
NFPA 96

Based on observation and staff interview, it was determined that the facility failed to properly maintain the heating, ventilating, and air conditioning system as required. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During the Life Safety Survey tour of the facility at 1:45 pm on June 19, 2012 with the Maintenance Director, it was noticed that there were black spots around the air conditioning vent in the Laboratory. This deficiency was noticed again at 2:50 pm on June 19, 2012 in the Emergency Room by Bed #14 there were dark spots around the air conditioning vent; at 3:28 pm on June 19, 2012 on the second floor dictation room there were dark spots around the air conditioning vent; and at 3:28 pm on June 19, 2012 in Telemetry Room 211 there was a brown spot on the ceiling tile.

During the Staff Interview between 1:46 pm and 3:30 pm on June 19, 2012, the Maintenance Director acknowledged the black spots around the air conditioning vent in the Laboratory. He also acknowledged the dark spots around the air conditioning vents in the Emergency Room by Bed #14 and the second floor Dictation Room, and the brown spot on the ceiling tile in Telemetry Room 211.

NFPA 101 Life Safety Code (2000)