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Tag No.: K0038
Based upon staff interview and observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain exit access to be readily accessible at all times in accordance with NFPA 101 18.2.2.2.1 & 7.2.1.
Findings include:
The Ultrasound room was observed to have a deadbolt style lock installed on the door. Doors shall be operable with not more than one releasing operation in accordance with NFPA 101 7.2.1.5.4.
Tag No.: K0046
Based upon observations made in the presence of the plant manager and administrator on 10/4/11, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 18.2.9.1 & 7.9.2.3.
Findings Include:
The transfer switch for the emergency power system was observed to not have a battery back up emergency light installed in the area in accordance with NFPA 110 5-3.1.
Tag No.: K0052
Based upon staff interview and observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 72, and NFPA 101 18.3.4.1& 9.6.1.4.
Findings include:
The fire alarm panel was observed to have no service tag on the panel that indicated that a qualified service provider has been maintaining the fire alarm system in accordance with NFPA 72 7-1.2.2.
Tag No.: K0144
Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 18.2.9.1 & 7.9.2.3.
Findings include:
The facility failed to provide records that demonstrated that the diesel powered generators were being tested under load at a minimum of 30% of the generators name plate rating thus requiring an annual generator load bank test in accordance with NFPA 110 6-4.2.2.
Tag No.: K0147
Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 & NFPA 70, The National Electrical Code.
Findings include:
The facility had several areas that were using power strips inappropriately to power small appliances as observed at the North Nurses station, X-ray office, IT office, and Respiratory Therapy office. Power strips are only to be used to power light electronics that the power strip has been tested for in accordance with NFPA 70 110-3(b