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Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 9/7/12 between 10:00 AM and 1:30 PM it is observed the self closing door is not latching to the door frame to Labor & Delivery room 3 and CT. This was corrected at time of survey.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 2 of 2 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 9/7/12 between 10:00 AM and 1:30 PM it is observed there is a magnet to hold open the self closing door and is not tied to the FAP (fire alarm panel) to release with the emergency systems to Soiled Utility, Clean Linen Storage and Bio Hazard room. This was corrected at time of survey. The magnet was removed from behind the doors.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 9/7/12 between 10:00 AM and 1;30 PM it is observed there is an open junction box above the ceiling tiles in the Pinet room. This was corrected at time of survey.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 9/7/12 between 10:00 AM and 1:30 PM it is observed the self closing door is not latching to the door frame to Labor & Delivery room 3 and CT. This was corrected at time of survey.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 2 of 2 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 9/7/12 between 10:00 AM and 1:30 PM it is observed there is a magnet to hold open the self closing door and is not tied to the FAP (fire alarm panel) to release with the emergency systems to Soiled Utility, Clean Linen Storage and Bio Hazard room. This was corrected at time of survey. The magnet was removed from behind the doors.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 of 2 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 9/7/12 between 10:00 AM and 1;30 PM it is observed there is an open junction box above the ceiling tiles in the Pinet room. This was corrected at time of survey.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed