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Based on observation and interview the facility failed to ensure all smoke barrier doors closed tightly when released from the automatic hold open device. The facility census was 11.

Findings included:

1. Observation during a tour of the facility conducted on 04/30/13 at 9:58 AM, showed the corridor smoke barrier doors, separating the main lobby from the corridor to the Radiology and Laboratory Departments, when released from the automatic hold open device did not close tightly. A gap of at least one-forth inch (1/4 " ) was observed between the edges of the doors.

2. Staff M, Director of Facilities, confirmed at that time the gap between the doors when closed was greater than one-eight inch (1/8 " ).

Section 2-3.1.7 of the National Fire Protection Association (NFPA 80) states: the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch + or ? 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

Based on observation and interview the facility failed to provide self-closing devices on all doors to hazardous areas. This deficient practice affects all occupants in that smoke compartment. The facility census was 11.

Findings included:

1. Observation, during a tour of the facility conducted on the morning of 04/30/13 at 9:20 AM, showed the door to the non-sprinkler Soiled Utility room, which opens into the patient corridor adjacent to the nurse ' s station in the Obstetrics Unit, was not provided with a self-closure device.

2. Observation during a tour of the facility conducted on the morning of 04/30/13 at 9:42 AM, showed the door to the non sprinkler Soiled Utility room, which opens into the patient corridor across the hall from patient room 102, was not provided with a self-closure device.

3. Staff M, Director of Facilities, confirmed at that time the doors to these hazardous areas were not provided with self-closure devices.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states: Any hazardous area shall be safe-guarded 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 system 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 interview the facility failed to develop a procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 11.

Findings included:

During an interview, conducted on 05/01/13 at 9:05 AM, Staff M, Director of Facilities, stated the facility did not have a procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.7.6.2 of the National Fire Protection Association (NFPA 101) states: sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Based on interview the facility failed to develop a procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 11.

Findings included:

During an interview, conducted on 05/01/13 at 9:05 AM, Staff M, Director of Facilities, stated the facility did not have a procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.6.1.8 of the National Fire Protection Association (NFPA 101) states: where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation and interview the facility failed to ensure all smoke barrier doors closed tightly when released from the automatic hold open device. The facility census was 11.

Findings included:

1. Observation during a tour of the facility conducted on 04/30/13 at 9:58 AM, showed the corridor smoke barrier doors, separating the main lobby from the corridor to the Radiology and Laboratory Departments, when released from the automatic hold open device did not close tightly. A gap of at least one-forth inch (1/4 " ) was observed between the edges of the doors.

2. Staff M, Director of Facilities, confirmed at that time the gap between the doors when closed was greater than one-eight inch (1/8 " ).

Section 2-3.1.7 of the National Fire Protection Association (NFPA 80) states: the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch + or ? 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

Based on observation and interview the facility failed to provide self-closing devices on all doors to hazardous areas. This deficient practice affects all occupants in that smoke compartment. The facility census was 11.

Findings included:

1. Observation, during a tour of the facility conducted on the morning of 04/30/13 at 9:20 AM, showed the door to the non-sprinkler Soiled Utility room, which opens into the patient corridor adjacent to the nurse ' s station in the Obstetrics Unit, was not provided with a self-closure device.

2. Observation during a tour of the facility conducted on the morning of 04/30/13 at 9:42 AM, showed the door to the non sprinkler Soiled Utility room, which opens into the patient corridor across the hall from patient room 102, was not provided with a self-closure device.

3. Staff M, Director of Facilities, confirmed at that time the doors to these hazardous areas were not provided with self-closure devices.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states: Any hazardous area shall be safe-guarded 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 system 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 interview the facility failed to develop a procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 11.

Findings included:

During an interview, conducted on 05/01/13 at 9:05 AM, Staff M, Director of Facilities, stated the facility did not have a procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.7.6.2 of the National Fire Protection Association (NFPA 101) states: sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Based on interview the facility failed to develop a procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 11.

Findings included:

During an interview, conducted on 05/01/13 at 9:05 AM, Staff M, Director of Facilities, stated the facility did not have a procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.6.1.8 of the National Fire Protection Association (NFPA 101) states: where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.