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Based on staff interview, observation and staff interview Ann Bates Leach Eye Hospital failed to comply with Life Safety 101 (2000) edition 19.3.6.2. The deficient practice would affect all smoke compartments, all occupants of the facility.

Findings:

During a tour of the facility on 11/06/2014 at 2:10 PM with the Director of Facilities it was observed that improper and/or unsealed Fire-Stop penetrations on the Ambulatory Surgery 6th floor next to the nurses's station. No documentation of meeting the Manufacturer's
specifications UL or nationally recognized products to seal penetrations to require fire barrier rating was provided.

During a tour of the facility on 11/06/2014 at 2:12 PM with the Director of Facilities it was acknowledged that improper and/or unsealed Fire-Stop penetrations on the Ambulatory Surgery 6th floor next to the nurses's station. No documentation of meeting the Manufacturer's UL or nationally recognized products to seal penetrations to require fire barrier rating was provided.

NFPA 101 (2000) edition
19.3.6.2

Based on observation and staff interview Anne Bates Leach Eye Hospital failed to comply with NFPA 101 (2000) edition 8.3.4, 19.2.2.2.6, 19.3.7.6. Doors shall be self closing or automatic closing. This deficiency could affect all occupants of the facility in case of a fire or other emergency.


Findings:

During a tour of the facility on 11/06/14 at 2:15 PM with facility's staff it was observed that the hardware on the smoke barrier doors was preventing the doors from working properly on release of the magnetic locks. The door closed but would not open. This deficiency was corrected on site.

During a tour of the facility on 11/06/14 at 2:18 PM with facility's staff it was acknowledged that the hardware on the smoke barrier doors was preventing the doors from working properly on release of the magnetic locks. The door closed but would not open. This deficiency was corrected on site.


NFPA 101 (2000) edition
8.3.4. 19.2.2.2.6, 19.3.7.6