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Through observation during the survey September 15, 2010, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Administrator:
a) The door to room #121 required excessive force to open and close.
b) The door to room #110A would not close and latch in to the door frame.
c) The door to room #103 would not latch in the frame when closed.
d) The doors to rooms #100 and #121 had gaps at the top between the door and the stop. These doors would not resist the passage of smoke.

Through observation during the survey September 15, 2010, it was determined that the facility failed to maintain the doors to the hazardous areas.

During the walk through of the facility with Administrator:
a) The Chart Room door was not equipped with a self-closing device. This room is over fifty square feet in area and utilized for the storage of combustibles.
b) The door to the supply closet in the southwest corridor contained an air transfer louver at the bottom of the door. This room is over fifty square feet in area and utilized for the storage of combustibles.

Through observation during the survey September 15, 2010, it was determined that the facility failed to illuminate all exit discharge areas with lighting arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness, in accordance with NFPA-101, Section 7.8.

During the walk through of the facility with the Administrator, the facility failed to illuminate the southwest exit with a light fixture containing two bulbs or two light fixtures.

Through record review, discussions, and observations during the survey September 15, 2010, it was determined that the facility failed to document the fire drills conducted quarterly on each shift.

During the review of the facility records with the Administrator and the Maintenance Director for the host hospital, documentation was not available to verify the facility conducted fire drills. The Administrator stated the facility conducts fire drills in unison with the host hospital. However, the facility did not document the drills. The survey confirmed that the fire alarm systems sound in both facilities during fire drills and the host hospital conducts fire drills. However, neither the host hospital nor the facility documented participation in the fire drills by the facility.

Through observation during the survey September 15, 2010, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Administrator, two sprinkler heads in the Visitor Consult/Quiet room had paint overspray. NFPA- 25, section 1-11.3, and 2-2.1.1 require; "Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

Through observation during the survey September 15, 2010, it was determined that the facility failed to install air conditioning equipment in accordance with NFPA-90A.

During the walk through of the facility with the Administrator, the administration suite of rooms contained a portable air conditioning unit installed with a flexible air connector through the open, fire-rated, ceiling hatch and connected into the building exhaust duct through a fabricated cover installed over the smoke-damper, inspection hatch. This survey could not determine whether the installation met all flame spread and testing requirements of NFPA90A, section 2-3.3. The open ceiling access did not meet the requirements of NFPA90A, section 2-3.4.6.

Through observation during the survey September 15, 2010, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Administrator:
a) The electrical junction box at the fire/smoke damper in the Administration suite did not have a cover plate over the box to protect the wiring.
b) The facility utilized a surge suppressor with a flexible cable in the Administration office to provide electrical power to a refrigerator, microwave, and toaster. [NFPA 70, Chapter 4, Article 400, Paragraph 400-8, "... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... "]