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Based on observation and interview, the facility failed to ensure corridors in the means of egress were continuously maintained clear of all obstructions per the requirements of:

NFPA 101 2012 Edition 19.2.3.4

The findings include:

Observation and interview with the Plant Operations Director, during the facility tour on 2/29/2024 between 2:22 PM and 3:10 PM confirmed the corridor in The E.D. had 2 Portable air conditioner units ducted into the ceiling located in the egress corridor.

The Plant Operations Director was present when the deficiency was identified and acknowledged by the Chief Executive Officer during the exit conference on 2/29/24.

Based on observation, the facility failed to prohibit the use of portable space heaters in patient care vicinity per the requirements of.

NFPA 101 2012 Edition 19.7.8

The findings include:

Observation with the Plant Operations Director, on 2/29/24 at 2:43 PM revealed the Admissions office had a portable space heater under staff desk in the patient care vicinity.

The Plant Operations Director was present when the deficiency was identified and acknowledged by the Chief Executive Officer during the exit conference on 2/29/24.