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Based on observation and interview, it was determined the facility failed to maintain required self closing doors on two of four floors.

Findings include;

1. Observation on May 22, 2024, between 9:22 a.m., and 10:53 a.m., revealed the following;

a. At 9:22 a.m., 3rd floor, stairtower # 1 had a gap in excess of tolerance on the strike side.
b. At 10:30 a.m., 1st floor, double doors into the soiled linen staging area failed to latch when tested.
c. At 10:53 a.m., 1st floor, double doors into the electric room, #155 were not self closing and lacked self closing devices.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the self closing door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas on one of four floors.

Findings include;

1. Observation on May 22, 2024, at 10:44 a.m., revealed an open wiring penetration around a blue wire above the exit doors in the boiler room, 1st floor.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the open wiring penetration.

2. Observation on May 22, 2024, at 11:00 a.m., revealed an open 3 inch square hole in the wall above the door in electrical room 118, on the 1st floor.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the open penetration of the wall.

Based on document review and interview, it was determined the facility failed to maintain one of one kitchen hood suppression systems.

Findings include;

1. Document review and interview on May 21, 2024, revealed the facility could not produce documentation that the kitchen hood suppression system had been inspected since June 2023.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the suppression system inspection was not completed.

Based on observation and interview, it was determined the facility failed to maintain corridor doors on two of four floors.

Findings include:

1. Observation on May 22, 2024, between 9:00 a.m., and 9:40 a.m., revealed the following;

a. At 9:00 a.m., 3rd floor, the double doors at elevator 3 failed to latch.
b. At 9:40 a.m., 2nd floor, dining room 267 failed to latch in the frame.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain the piped in medical gas system in one of five smoke compartments.

Findings include:

1. Observation on May 21, 2024, at 1:34 p.m., revealed steel metallic cabling in contact with the copper medical gas lines above the ceiling near the clean supply room on the 1st floor.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the dissimilar metal in contact with the copper tubing.

Based on observation and interview, it was determined the facility failed to maintain the medical gas system on one of four floors.

Findings include:

1. Observation on May 22, 2024, revealed the medical gas alarm panel at the NE nurse station, near room 410, 4th floor was not powered and the display was not showing any function.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the med-gas alarm panel was not functioning.

Based on observation and interview, it was determined the facility failed to maintain power cords in one of five smoke compartments.

Findings include:

1. Observation on May 21, 2024, at 1:07 p.m., revealed the bed cord in exam room 2 on the 1st floor was pinched to the floor by the bed.

Interview with the facilities director and facility maintenance representative on May 22, 2024, at 11:30 a.m., confirmed the cord was pinched.