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Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance throughout the facility.

Findings Include:
Observation on 6/10/10 at 9:56am revealed the following:

The loading dock doors were being propped open with bags of salt.

Interview with the facility administrator confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain exit access in one instance throughout the facility.

Findings Include:

Observation on 6/10/10 at 8:37am revealed the following:

The horizontal sliding doors at the building entrances can be locked against egress.

Interview with the facility administrator confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain sprinkler requirements in three instance throughout the facility.

Findings Include:
Observation on 6/10/10 revealed the following:

a) At 9:08am, the sprinkler heads in the orange unit on the third floor were not installed properly.
b) At 9:10am, the sprinkler heads in room 311 were obstructed by light fixtures.
c) At 9:17am, the play area on the second floor across from 249 lacked sprinkler protection.

Interview with the facility administrator confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one instance throughout the facility.

Findings Include:Observation on 6/10/10 at 9:44am revealed the following:

There were cigarettes thrown into the west access pit where there were dried leaves.

Interview with the facility administrator confirmed the condition existed on the time and date stated above.

Based on observation and interview, it was determined the facility failed to maintain oxygen storage requirements in one instance throughout the facility.

Findings Include:

Observation on 6/10/10 at 10:14am revealed the following:

There were unsecured oxygen cylinders in the EMT room 176.

Interview with the facility administrator confirmed the condition existed on the time and date stated above.

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations.

Findings include:

Observation on 6/10/10 at 10:19am revealed the following:

There was cooking fuel in the kitchen area across from the first floor conference room. Cooking fuel is not permitted in a health care occupancy.

Interview with the facility administrator confirmed the condition existed on the time and date stated above.