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Based on observation and interview the facility failed to provide self-closing on doors to all hazardous areas. This deficient practice affects all occupants within that smoke compartment. The facility census was 47.

Findings included:

1. Observation on 11/27/12 at 9:40 AM during a tour of the facility showed the door to the Soiled Utility room, a hazardous area, located in the Obstetrics Department was not currently provided with an automatic self-closing device.

2. Staff H, Plant Operations Director, confirmed at that time the door was not provided with an automatic self-closing device.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states 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.

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. The facility census was 47.

Findings included:

During an interview, conducted at 8:25 AM on 11/29/12, Staff H, Plant Operations Director, 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, Standard 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. The facility census was 47.

Findings included:

During an interview, conducted at 8:25 AM on 11/29/12, Staff H, Plant Operations Director, 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.