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Based on observation, the facility failed to maintain corridor doors in proper working order so that there are no impediments the do not allow them to close in the event of a fire. This affects 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed the following:

1. There was a kickdown on the door to Room 119.

2. there was a trash can holding the door open to the Wellness Room.

Based on observation, the facility failed to maintain smoke doors to close properly. This affects 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed the smoke doors by the Ambulance Office did not close properly.

Based on observation, the facility failed to separate storage rooms properly. This affects 1 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no self closer on the Old Delivery Room Door which is now being used for mass storage.

Based on observation, the facility failed to extend all sidewalk to the public way. This affects all staff using the Administration Wing. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no sidewalk to the public way outside the north Administration exit.

Based on observation, the facility failed to provide doors that open with one motion. These doors were equipped with separate deadbolts. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was deadbolts on the following doors: Cardiac Rehab, Kitchen (2), Physicians Room, Cardiac Office, Accounts Payable Office, Room 119, and the UR Room.

Based on observation, the facility failed to provide proper lighting on the exterior of the building. This affects 3 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no exterior exit lighting requiring to bulbs to get occupants away from the building at the following exits: OPS South Exit, OR Exit, ER Exit, and the Loading Dock.

Based on observation, the facility failed to properly maintain emrgency lights. This affects 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed the following:

1. Both Operating Rooms were not equipped with battery powered emergency lights.

2. The emergency light by the generator was inoperable.

3. According to the Maintenance Staff there was no testing records for the battery powered emergency lights. The testing required is for 30 seconds monthly and 90 minutes yearly.

Based on observation, the facility failed to have exit signs were required. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no exit signs at the following locations: south end of the Administration Hall, by the Ambulance Office, by Room 107, by Room 108, by the Nurses Station, and in the OPS Hall by the Sitz Bath Room

Based on Observation, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2--15-11, revealed the following:

1. The fire alarm panel was not labeled properly wit the location of the breaker for the fire alarm.

2. The breaker for the fire alarm was not locked nor was it labeled.

Based on observation, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed the the following:

1. There was an escutcheon ring ajar in the Bathroom in the Administration Area.

2. There were dirty sprinkler head in the IT Office, Radiology Reading Room, Admitting Room, Med Room, the Abmulance Office, Old Nursery, and the Laundry Room.

Based on observation, the facility failed to maintain fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This affects 2 of 5 smoke zones The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no monthly inspection for January of 2011 on the extinguisher by the UR Room and the extinguisher in the West OR Corridor.

Based on observation, the facility failed to properly maintain cooking equipment and cooking suppression equipment in accordance with National Fire Protection Association (NFPA) 96. This affects 1 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed the following:

1. There was no monthly inspection on the suppression system.

2. One of six pilot lights on the stove was not lite.

Based on observation, the facility failed to maintain corridors clear of obstructions. This affects 2 of 5 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 2-15-11, revealed there was chairs, carts, a blanket warmer, and wheel chairs in the North Hall and the OPS Hall.

2. Observations on 2-15-11, revealed there was 2 open Wallaroos on the OPS Hall. Also note they were not self closing.

Based on observation, the facility failed to display oxygen in use signs were needed. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no oxygen in use signs at the following locations: North Wing Storage, Room 102, Storage Room by Room 108, and the OPS Utility Closet.

Based on observation, the facility failed to have an annunciator panel for the generator in accordance with National Fire Protection Association (NFPA) 110 and 99. This affects the entire building. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 2-15-11, revealed there was no annunciator panel for the generator. The annunciator panel must be in an area that is supervised 24 hours a day.