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Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of three floors.

Findings include:

1. Observation on November 25, 2024, at 12:33 p.m., revealed the first floor common wall door with the hospital occupancy required adjustment to fully latch.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the common wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure in one location, affecting one of four floors.

Findings include:

1. Observation on November 25, 2024, at 9:40 a.m., revealed penetration of the fourth floor portion of the east stair tower enclosure was filled with spackling material (located above the stair tower door).

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed stair tower enclosure deficiency.

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower in two locations, affecting three of three floors.

Findings include:

1. Observation on November 25, 2024, between 12:33 p.m., and 12:47 p.m., revealed the second and third floor, east stair tower enclosure doors were not smoke-tight.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the stair tower enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain install and maintain exit signage in two locations, affecting one of four floors.

Findings include:

1. Observation on November 25, 2024, between 9:50 a.m., and 9:53 a.m., revealed the following:

a. 9:50 a.m., the exit sign chevron, located closest to the fourth floor, Elevator Lobby, pointed to the right, instead of left.
b. 9:53 a.m., the fourth floor, Elevator Lobby area, lacked exit signage, pointing to the east stair tower enclosure.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed exit signage deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting three of four floors.

Findings include:

1. Observation on November 25, 2024, between 10:11 a.m., and 11:37 a.m., revealed the following:

a. 10:11 a.m., the fourth floor, Examination Room 407 door was not smoke-tight.
b. 10:14 a.m., the fourth floor, Room 413 door was not smoke-tight.
c. 11:37 a.m., the second floor, east wing Data Closet door was not smoke-tight.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of three floors.

Findings include:

1. Observation on November 25, 2024, at 12:50 p.m., revealed a penetration of the first floor, Nutrition Room door.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation walls, affecting one of four floors.

Findings include:

1. Observation on November 25, 2024, between 11:38 a.m., and 11:44 a.m., revealed the following:

a. 11:38 a.m., a penetration of the smoke barrier separation wall, above the doors, entering PACU.
b. 11:44 a.m., the smoke barrier wall was not sealed between smoke barrier wall and fluted decking, located above the smoke barrier doors, at the top of the second floor ramp.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed smoke barrier separation wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation doors, affecting two of four floors.

Findings include:

1. Observation on November 25, 2024, between 11:29 a.m., and 11:40 a.m., revealed the following:

a. 11:29 a.m., the smoke barrier separation door vision panels, located closest to the third floor A Elevators, lacked fire-rated glass and rated frame assemblies.
b. 11:40 a.m., the second floor, "ramp" smoke barrier separation door's panic hardware "end cap" was missing.

Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation door deficiencies.