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Based on observations, the facility failed to properly protect corridors in accordance with NFPA 101 section 18.3.6.1, 18.3.6.2, 18.3.6.4, 18.3.6.5. The deficient practice affected one (1) of two (2) smoke compartments.

Findings Include:

On 2/8/16 at 11:45 AM, observation revealed the window of the Pharmacy 2108 was open to the corridor and this created an opening to allow the transfer of smoke in corridor. The sliding door of the window to Pharmacy 2108 did not close when the fire alarm was activated, and the sliding door lacked a manual closing device on the corridor side.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/8/16.

Based on observations, the facility failed to properly protect smoke barriers in accordance with NFPA 101 sections 18.3.7.5, 18.3.7.6, 18.3.7.8. The deficient practice affected one (1) of two (2) smoke compartments.

Findings Include:

On 2/8/16 at 2:30PM, observation revealed one (1) inch gaps in the following smoke barrier doors in the following areas:

1) Smoke barrier door near PFT LAB Room 2111
2) Smoke barrier door near IV ADDMIX Room 2113
3) Smoke barrier door near Clean Room 2139
4) Smoke barrier door near On Call Room 2071

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/8/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 9.7, 18.3.2.1, and 18.3.5.1. The deficient practice affected one (1) of two (2) smoke compartments.

Findings Include:

On 2/8/16 at 1:25PM, observation revealed open penetrations in the following hazardous areas of the facility:

1) Soiled Linen Room 2066
2) Environmental Services Room 2023
3) Gas Storage Room 2014

It was also observed Room 2117 was being used as storage, so the door of Room 2117 lacked a 45 minute fire rating and self closing device.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/8/16.

Based on observations, the facility failed to properly protect corridors in accordance with NFPA 101 section 18.3.6.1, 18.3.6.2, 18.3.6.4, 18.3.6.5. The deficient practice affected one (1) of two (2) smoke compartments.

Findings Include:

On 2/8/16 at 11:45 AM, observation revealed the window of the Pharmacy 2108 was open to the corridor and this created an opening to allow the transfer of smoke in corridor. The sliding door of the window to Pharmacy 2108 did not close when the fire alarm was activated, and the sliding door lacked a manual closing device on the corridor side.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/8/16.

Based on observations, the facility failed to properly protect smoke barriers in accordance with NFPA 101 sections 18.3.7.5, 18.3.7.6, 18.3.7.8. The deficient practice affected one (1) of two (2) smoke compartments.

Findings Include:

On 2/8/16 at 2:30PM, observation revealed one (1) inch gaps in the following smoke barrier doors in the following areas:

1) Smoke barrier door near PFT LAB Room 2111
2) Smoke barrier door near IV ADDMIX Room 2113
3) Smoke barrier door near Clean Room 2139
4) Smoke barrier door near On Call Room 2071

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/8/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 9.7, 18.3.2.1, and 18.3.5.1. The deficient practice affected one (1) of two (2) smoke compartments.

Findings Include:

On 2/8/16 at 1:25PM, observation revealed open penetrations in the following hazardous areas of the facility:

1) Soiled Linen Room 2066
2) Environmental Services Room 2023
3) Gas Storage Room 2014

It was also observed Room 2117 was being used as storage, so the door of Room 2117 lacked a 45 minute fire rating and self closing device.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/8/16.