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Based on observation and interview the facility failed to assure all doors to hazardous areas completely closed and latched in the door frame to maintain a separation from the corridor. This deficient practice affects 2 of the 5 smoke compartments containing patient rooms. The facility census was six.

Findings included:

Observation during a tour of the facility, conducted on the morning of 08/28/12, showed the following:

1. Observation at 9:04 AM showed the automatic closure device on the door to the dirty utility room, located adjacent to patient room 107, would not completely close the door and latch in the door frame when tested.

2. Staff L, Facilities Manager, confirmed at that time the door would not completely close and latch in the door frame.

3. Observation at 9:34 AM showed the door to the dirty utility room, located in the Intensive Care Unit (ICU), was not provided with an automatic closure device to assure the door remained latched in the door frame.

4. Staff L, Facilities Manager, confirmed at that time the door to the dirty utility room in the ICU was not provided with an automatic door closure.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants in the facility. The facility census was six.

Findings included:

1. Observation on 08/28/12 at 10:33 AM during a tour of the facility showed the area where the emergency generator is located was not provided with a battery emergency light of at least 1 and ? hour duration to provide task illumination in the event of mechanical failure of the generator.

2. Staff L, Facilities Manager, confirmed at that time a battery emergency lighting unit was not provided for the generator.

Section 3-4.2.2.2 of the National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on document review the facility failed to conduct a fire drills on at least a quarterly basis for each shift. This deficient practice affects all occupants of the facility. The facility census was six.

Findings included:

Document review of the facilities fire drill records for the previous year, conducted on the afternoon of 08/28/12, showed facility staff on the third shift (11:00 PM to 7:00 AM) participated in only 2 drills during the previous year. One drill took place on 09/19/11 and the only other drill took place on 06/06/12.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Based on document review the facility failed to conduct a certification inspection of the sprinkler system on at least an annual basis. This deficient practice affects all occupants in the facility. The facility census was six.

Findings included:

1. Review of the facility sprinkler system inspection documents, conducted on the afternoon of 08/28/12, showed the last 2 inspections of the sprinkler system by an outside contractor had occurred 06/23/10 and 07/12/11.

Section 5.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Based on document review the facility failed to conduct a semi-annual inspection of the range hood suppression system in the kitchen. This deficient practice affects all occupants in the facility. The facility census was six.

Findings included:

1. Review of the facility range hood suppression system inspection documents, conducted on the afternoon of 08/28/12, showed the last 2 inspections by an outside contractor had occurred on 09/28/11 and 08/20/12.

Section 8-2 of the National Fire Protection Association (NFPA 96) states an inspection and servicing of the fire-extinguishing system and listed exhaust hoods shall be made at least every 6 months by properly trained and qualified persons.

Based on observation and interview the facility failed to assure all doors to hazardous areas completely closed and latched in the door frame to maintain a separation from the corridor. This deficient practice affects 2 of the 5 smoke compartments containing patient rooms. The facility census was six.

Findings included:

Observation during a tour of the facility, conducted on the morning of 08/28/12, showed the following:

1. Observation at 9:04 AM showed the automatic closure device on the door to the dirty utility room, located adjacent to patient room 107, would not completely close the door and latch in the door frame when tested.

2. Staff L, Facilities Manager, confirmed at that time the door would not completely close and latch in the door frame.

3. Observation at 9:34 AM showed the door to the dirty utility room, located in the Intensive Care Unit (ICU), was not provided with an automatic closure device to assure the door remained latched in the door frame.

4. Staff L, Facilities Manager, confirmed at that time the door to the dirty utility room in the ICU was not provided with an automatic door closure.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants in the facility. The facility census was six.

Findings included:

1. Observation on 08/28/12 at 10:33 AM during a tour of the facility showed the area where the emergency generator is located was not provided with a battery emergency light of at least 1 and ? hour duration to provide task illumination in the event of mechanical failure of the generator.

2. Staff L, Facilities Manager, confirmed at that time a battery emergency lighting unit was not provided for the generator.

Section 3-4.2.2.2 of the National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on document review the facility failed to conduct a fire drills on at least a quarterly basis for each shift. This deficient practice affects all occupants of the facility. The facility census was six.

Findings included:

Document review of the facilities fire drill records for the previous year, conducted on the afternoon of 08/28/12, showed facility staff on the third shift (11:00 PM to 7:00 AM) participated in only 2 drills during the previous year. One drill took place on 09/19/11 and the only other drill took place on 06/06/12.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Based on document review the facility failed to conduct a certification inspection of the sprinkler system on at least an annual basis. This deficient practice affects all occupants in the facility. The facility census was six.

Findings included:

1. Review of the facility sprinkler system inspection documents, conducted on the afternoon of 08/28/12, showed the last 2 inspections of the sprinkler system by an outside contractor had occurred 06/23/10 and 07/12/11.

Section 5.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Based on document review the facility failed to conduct a semi-annual inspection of the range hood suppression system in the kitchen. This deficient practice affects all occupants in the facility. The facility census was six.

Findings included:

1. Review of the facility range hood suppression system inspection documents, conducted on the afternoon of 08/28/12, showed the last 2 inspections by an outside contractor had occurred on 09/28/11 and 08/20/12.

Section 8-2 of the National Fire Protection Association (NFPA 96) states an inspection and servicing of the fire-extinguishing system and listed exhaust hoods shall be made at least every 6 months by properly trained and qualified persons.