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Based on observations, the facility failed to maintain the doors.

The finding included:

Observation on 5/16/17 at 10:11 AM, revealed the nourishment room door latch was 59 ½ above the finished floor. National Fire Protection Association (NFPA) 101, 19.2.2.2.1 (2012 Edition) NFPA 101, 7.2.1.5.10.1 (2012 Edition)

The maintenance director was present when this deficiency was identified and it was later acknowledged by the administrator during the exit conference on 5/16/17.

Based on observations, the facility failed to maintain the hazardous areas.

The finding included:

Observation on 5/16/17 at 10:56 AM, revealed numerous unsealed ceiling penetrations in the boiler room. NFPA 101, 19.3.2.1 (2012 Edition)

The maintenance director was present when this deficiency was identified and it was later acknowledged by the administrator during the exit conference on 5/16/17.

Based on observations, the facility failed to maintain the smoke detectors.

The findings included:

Observation on 5/16/17 at 10:11 AM, revealed smoke detectors next to air flow in the following locations:
a. Nurse station med room
b. X ray waiting room
c. Xray tech work area. NFPA 101, 19.3.4.5.1 (2012 Edition) NFPA 101, 9.1.6.3 (2012 Edition) NFPA 72, 17.7.4.1 (2010 Edition)

The maintenance director was present when these deficiencies were identified and they were later acknowledged by the administrator during the exit conference on 5/16/17.

Based on observations, the facility failed to install sprinklers in required areas.

The findings included:

1. Observation on 5/16/17 at 10:22 AM, revealed no sprinkler coverage in the pharmacy storage closet. NFPA 19.3.5.8 (2012 Edition)

2. Observation on 5/16/17 at 11:00 AM, revealed the back ambulance drive under canopy constructed of combustible material and combustible storage underneath. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.1.1 (2012 Edition) NFPA 13, 8.15.7.1 (2010 Edition) NFPA 13, 8.15.7.5* (2010 Edition)

The maintenance director was present when these deficiencies were identified and they were later acknowledged by the administrator during the exit conference on 5/16/17.

Based on observations, the facility failed to maintain the sprinkler system.

The finding included:

Observation on 5/16/17 at 2:06 PM, revealed HVAC duct lines load bearing on the sprinkler line above the ceiling in the ER by the ambulance entrance. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.1.1 (2012 Edition) NFPA 13, 26.1 (2010 Edition) NFPA 25, 5.2.2.2(2011 Edition)

The maintenance director was present when this deficiency was identified and it was later acknowledged by the administrator via phone conference on 5/16/17.

Based on observations, the facility failed to maintain the generator.

The finding included:

Observation on 5/16/17 at 2:15 PM, revealed the emergency powered diesel generator was not anchored to the concrete pad. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.3 (2012 Edition) NFPA 110, 7.1.3 (2010 Edition) NFPA 110, 7.4.3 (2010 Edition)

The maintenance director was present when this deficiency was identified and it was later acknowledged by the administrator via phone conference on 5/16/17.

Based on observations, the facility failed to maintain the medical gas lines.

The finding included:

Observation on 5/16/17 at 10:56 AM, revealed dissimilar metals in contact with medical gas lines throughout the facility. NFPA 99, 5.1.10.11.2 (2012 Edition)

The maintenance director was present when this deficiency was identified and it was later acknowledged by the administrator during the exit conference on 5/16/17.

Based on observations, the facility failed to prohibit the use of extension cords.

The finding included:

Observations on 5/16/17 at 10:23 AM, revealed the use of extension cords in the following locations:
a. DON s office
b. Doctors lounge (x2)
c. Lab supervisors office. NFPA 99, 10.2.4 (2012 Edition)

The maintenance director was present when these deficiencies were identified and they were later acknowledged by the administrator during the exit conference on 5/16/17.