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Based on observation and interview, the facility failed to maintain doors in smoke barriers to be rated and automatic closing. This deficient practice could affect staff and patients in the ICU smoke zone by allowing smoke to travel into separate smoke zone. Findings are:

Observation on 2/26/2013, between 1:30 P.M. and 4:00 P.M., revealed the east ICU smoke doors have a gap at the bottom of the doors. Observations were verified by Maintenance Staff A at the time of the survey.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25. This deficient practice could affect the staff and patients in the radiology smoke zone by reducing the ability of the automatic fire sprinkler system to extinguish the fire, which could cause the fire to spread, in this facility. Findings are:

On 2/26/2013 between 1:30 P.M. and 4:00 P.M., it was observed that the fire sprinkler head located in the bone density room missing an escutcheon. Maintenance Staff A confirmed that the escutcheon was missing.

Based on observation and interview, the facility failed to maintain doors in smoke barriers to be rated and automatic closing. This deficient practice could affect staff and patients in the ICU smoke zone by allowing smoke to travel into separate smoke zone. Findings are:

Observation on 2/26/2013, between 1:30 P.M. and 4:00 P.M., revealed the east ICU smoke doors have a gap at the bottom of the doors. Observations were verified by Maintenance Staff A at the time of the survey.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25. This deficient practice could affect the staff and patients in the radiology smoke zone by reducing the ability of the automatic fire sprinkler system to extinguish the fire, which could cause the fire to spread, in this facility. Findings are:

On 2/26/2013 between 1:30 P.M. and 4:00 P.M., it was observed that the fire sprinkler head located in the bone density room missing an escutcheon. Maintenance Staff A confirmed that the escutcheon was missing.