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Based on observations and interviews, the facility failed to provide building construction that is in accordance with 19.1.6.2,19.1.6.3, 19.1.6.4,19.3.5.1. The facility had a capacity of 25 and a census of 13.

Findings include:

1. Observations and staff interviews on 05/24/12, revealed a gap(approximately 1/2 inch) around the air vent in the Admissions Office.

2. Observations and staff interviews on 05/24/12, revealed a hole (approximately 2 x 3 inches) located in the OB Air Handling Unit Room located above AHU.

3. Observations and staff interviews on 05/24/12, revealed a gap(approximately 1/4 inch) around the sprinkler pipe located in the Rehabilitation Room.

4. Observations and staff interviews on 05/24/12, revealed a gap (approximately 1/4 inch) around pipes located on the west wall of the Lower Boiler Room.

5. Observations and staff interviews on 05/24/12, revealed a missing ceiling tile located in X-Ray Room 1.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to provide hazardous areas in accordance with 8.4.1, 19.3.5.4, 19.3.2.1. This affects 2 of 9 smoke zones. The facility has a capacity of 25 and a census of 13.

Findings include:

1. Observations and staff interviews on 05/24/12, revealed the door to Room 124 was not equipped with door closing hardware.

2. Observations and staff interviews on 05/24/12, revealed the door to the Soiled Utility Room in the OB Ward was not equipped with door closing hardware.

Maintenance Staff A verified this observation.

Based on observations and interviews, the facility failed to maintain exits that are accessible at all times in accordance with 7.1, 18.2.1, 19.2.1. This affects the entire facility.

Findings include:

Observations and staff interviews on 05/24/12, revealed a dead bolt lock located on the Main Exit Door.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9.1. This affects the entire facility.

Findings include:

Observations and staff interviews on 05/25/12, revealed the emergency lighting above the door to the basement did not function properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide a fire alarm in accordance with 9.6.1.3. This affects the entire facility. The facility has a capacity of 25 and a census of 13.

Findings include:

Record reviews and staff interviews on 05/24/12, revealed the facility failed to conduct a required sensitivity test. The last documented test was on 12/18/09.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide a sprinkler system in accordance with National Fire Protection Association 13 1999 edition, National Fire Protection Association 25, 1999 edition, 19.3.5. This affects the entire facility. The facility has a capacity of 25 and a census of 13.

Findings include:

Record review and staff interviews on 05/25/12, revealed the facility was not conducting quareterly sprinkler inspections.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide a complete sprinkler system in accordance with National Fire Protection Association 13, 1999 edition, National Fire Protection Association 25,1999 edition, 18.7.6, 19.7.6, 4.6.12. This affects 1 of 9 smoke zones. The facility had a capacity of 25 and a census of 13.

Findings include:

1. Observations and staff interviews on 05/24/12, revealed a missing escutcheon ring on the sprinkler head located in the Dietary Mop Closet.

2. Observations and staff interviews on 05/24/12, revealed a missing escutcheon ring on the sprinkler head located in the corridor by the Dietary Mop Closet.

3. Observations and staff interviews on 05/24/12, revealed a dirty sprinkler head located by the kitchen fan in the Kitchen.

Maintenance Staff A verified these observations.

Based on observations and staff interview, the facility failed to provide fire extinguishers in accordance with 9.7.4.1, National Fire Protection Association 10, 1999 edition, 19.3.5.6. This affects the entire facility.

Findings include:

Observations and staff interviews on 05/25/12, revealed the facility was not inspecting the fire extinguishers on a monthly basis.

Maintenance Staff A verified this observation

Based on record reviews and interview, the facility failed to provide smoke dampers in accordance with National Fire Protection Association 90A 1999 edition. This affects the entire facility. The facility has a capacity of 25 and a census of 13.

Findings include:

Record reviews and staff interviews on 05/24/12, revealed the facility did not have documents to show the facilities dampers have been inspected. Maintenance Staff A contacted the inspection company and was informed the 6 year inspection was not conducted.

Maintenance Staff A verified this observation.

Based on observations and interview, the facility failed to maintain their electrical system in accordance with National Fire Protection Association 70, National Electrical Code 9.1.2. This affects 1 of 9 zones. The facility has a capacity of 25 and a census of 13.

Findings include:

Observations and staff interview on 05/24/12, revealed a fan plugged into a surge protector in Office 122.

Maintenance Staff A verified this observation.

Based on observations and interview, the facility failed to maintain their electrical system in accordance with National Fire Protection Association 70, National Electrical Code 9.1.2. This affects the entire facility.

Findings include:

Observations and staff interview on 05/25/12, revealed the outlet located by the sink in the Employee Breakroom was not a Ground Fault Circuit Interrupter outlet.

Maintenance Staff A verified this observation.

Based on observations and interviews, the facility failed to provide building construction that is in accordance with 19.1.6.2,19.1.6.3, 19.1.6.4,19.3.5.1. The facility had a capacity of 25 and a census of 13.

Findings include:

1. Observations and staff interviews on 05/24/12, revealed a gap(approximately 1/2 inch) around the air vent in the Admissions Office.

2. Observations and staff interviews on 05/24/12, revealed a hole (approximately 2 x 3 inches) located in the OB Air Handling Unit Room located above AHU.

3. Observations and staff interviews on 05/24/12, revealed a gap(approximately 1/4 inch) around the sprinkler pipe located in the Rehabilitation Room.

4. Observations and staff interviews on 05/24/12, revealed a gap (approximately 1/4 inch) around pipes located on the west wall of the Lower Boiler Room.

5. Observations and staff interviews on 05/24/12, revealed a missing ceiling tile located in X-Ray Room 1.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to provide hazardous areas in accordance with 8.4.1, 19.3.5.4, 19.3.2.1. This affects 2 of 9 smoke zones. The facility has a capacity of 25 and a census of 13.

Findings include:

1. Observations and staff interviews on 05/24/12, revealed the door to Room 124 was not equipped with door closing hardware.

2. Observations and staff interviews on 05/24/12, revealed the door to the Soiled Utility Room in the OB Ward was not equipped with door closing hardware.

Maintenance Staff A verified this observation.

Based on observations and interviews, the facility failed to maintain exits that are accessible at all times in accordance with 7.1, 18.2.1, 19.2.1. This affects the entire facility.

Findings include:

Observations and staff interviews on 05/24/12, revealed a dead bolt lock located on the Main Exit Door.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9.1. This affects the entire facility.

Findings include:

Observations and staff interviews on 05/25/12, revealed the emergency lighting above the door to the basement did not function properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide a fire alarm in accordance with 9.6.1.3. This affects the entire facility. The facility has a capacity of 25 and a census of 13.

Findings include:

Record reviews and staff interviews on 05/24/12, revealed the facility failed to conduct a required sensitivity test. The last documented test was on 12/18/09.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide a sprinkler system in accordance with National Fire Protection Association 13 1999 edition, National Fire Protection Association 25, 1999 edition, 19.3.5. This affects the entire facility. The facility has a capacity of 25 and a census of 13.

Findings include:

Record review and staff interviews on 05/25/12, revealed the facility was not conducting quareterly sprinkler inspections.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide a complete sprinkler system in accordance with National Fire Protection Association 13, 1999 edition, National Fire Protection Association 25,1999 edition, 18.7.6, 19.7.6, 4.6.12. This affects 1 of 9 smoke zones. The facility had a capacity of 25 and a census of 13.

Findings include:

1. Observations and staff interviews on 05/24/12, revealed a missing escutcheon ring on the sprinkler head located in the Dietary Mop Closet.

2. Observations and staff interviews on 05/24/12, revealed a missing escutcheon ring on the sprinkler head located in the corridor by the Dietary Mop Closet.

3. Observations and staff interviews on 05/24/12, revealed a dirty sprinkler head located by the kitchen fan in the Kitchen.

Maintenance Staff A verified these observations.

Based on observations and staff interview, the facility failed to provide fire extinguishers in accordance with 9.7.4.1, National Fire Protection Association 10, 1999 edition, 19.3.5.6. This affects the entire facility.

Findings include:

Observations and staff interviews on 05/25/12, revealed the facility was not inspecting the fire extinguishers on a monthly basis.

Maintenance Staff A verified this observation

Based on record reviews and interview, the facility failed to provide smoke dampers in accordance with National Fire Protection Association 90A 1999 edition. This affects the entire facility. The facility has a capacity of 25 and a census of 13.

Findings include:

Record reviews and staff interviews on 05/24/12, revealed the facility did not have documents to show the facilities dampers have been inspected. Maintenance Staff A contacted the inspection company and was informed the 6 year inspection was not conducted.

Maintenance Staff A verified this observation.

Based on observations and interview, the facility failed to maintain their electrical system in accordance with National Fire Protection Association 70, National Electrical Code 9.1.2. This affects 1 of 9 zones. The facility has a capacity of 25 and a census of 13.

Findings include:

Observations and staff interview on 05/24/12, revealed a fan plugged into a surge protector in Office 122.

Maintenance Staff A verified this observation.

Based on observations and interview, the facility failed to maintain their electrical system in accordance with National Fire Protection Association 70, National Electrical Code 9.1.2. This affects the entire facility.

Findings include:

Observations and staff interview on 05/25/12, revealed the outlet located by the sink in the Employee Breakroom was not a Ground Fault Circuit Interrupter outlet.

Maintenance Staff A verified this observation.