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Based on observation and interview, it was determined the facility failed to maintain the fire rating of the occupancy separation doors on two of four levels of the component.

Findings include:

1. Observation on March 29, 2022, between 8:35 am and 8:55 am, revealed the following separation doors failed to latch when released from their hold open magnets.

a. At 8:35 am, Lower Level, Doors P0600.
b. At 8:55 am, 1st floor doors D1186.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas on one of five levels of the component.

Findings include:

1. Observation on March 29, 2022, at 10:18 am, revealed the door to soiled utility room 4642 on the fourth floor failed to latch in the corresponding frame.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the door lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas on two of four levels of the component.

Findings include:

1. Observation on March 29, 2022, at 1:20 pm, revealed the door to the soiled cart room on the 1st floor, room 1895, failed to latch in the frame.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the door lacked positive latching.

2. Observation on march 29, 2022, at 2:15 pm, revealed the door to the HVAC area in the basement failed to latch in the frame.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the door lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiation devices accessible at all times on one of four levels of the component.

Findings include:

1. Observation on March 29, 2022, revealed a fire alarm pull station was covered and not accessible by a cart on the 3rd floor near stair tower SC.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the pull station was blocked by a cart.

Based on interview and observation, it was determined the facility failed to maintain portable fire extinguishers in one location of the component.

Findings include;

1. Observation on March 28, 2022, at 1:58 pm, revealed the portable fire extinguisher in the in the corridor outside the employee lounge, lower level, was blocked by various items.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the extinguisher was blocked from easy access.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers on one of five levels of the component.

Findings include;

1. Observation on March 29, 2022, at 9:05 am, revealed a fire extinguisher on the right side after entering the Miller Confrence Center from the Main Lobby area was over due for annual inspection.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the fire extinguisher annual inspection tag was dated 2021.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers on one of four levels of the component.

Findings include:

1. Observation on March 29, 2022, revealed a fire extinguisher was blocked by a chair across from room 3313 on the 3rd floor.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the chair was blocking the fire extinguisher.

Based on observation and interview, it was determined the facility failed to maintain cooridor doors on one of four levels of the component.

Findings include:

1. Observation on March 29, 2022 between 11:20 am and 11:25 am, revealed the following doors did not latch or were not smoke tight;

a. At 11:20 am, 3rd floor room 3201 failed to latch.
b. At 11:25 am, 3rd floor room 3216 was not smoke tight while latched in the frame.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the deficient doors.

Based on observation and interview, it was determined the facility failed to maintain corridor doors on two of four floors of the component.

Findings include;

1. Observation between 9:30 am and 9:52 am, on March 29, 2022, revealed the following corridor doors failed to latch in the corresponding frame;

a. At 9:30 am, 2nd floor, 2619.
b. At 9:32 am, 2nd floor, 2626.
c. At 9:50 am, 3rd floor, 3616.
d. At 9:52 am, 3rd floor, 3619.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance of smoke barrier walls in one location of the component.

Findings include;

1. Observation on March 28, 2022, at 1:15 pm, revealed an open wring penetration of the smoke barrier wall above the ceiling near Preop bay # 1.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the area around some data wiring was not sealed.

Based on document review and interview, it was determined the facility failed to conduct required quarterly fire drills at random times and conditions.

Findings include:

1. Document review on March 28, 2022, between 9:30 am and 12:00 pm, revealed the previous 12 months of third shift fire drills were conducted within approximatley the same hour or time of the day.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the 3rd shift drills were not conducted at random intervals.

Based on observation and interview, it was determined the facility failed to properly store trash receptacles greater than 32-gallon capacity when left unattended on one of four levels of the component.

Findings include:

1. Observation on March 29, 2022, at 1:30 pm, revealed a cart containing trash with a capacity exceeding 32 gallons was being stored in the back corridor of the Cafe.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the trash was being stored in the corridor.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of surge protection devices on one of four levels of the component.

Findings include:

1. Observation on March 29, 2022, at 2:55 pm, revealed a toaster and a microwave were being powered by a surge protection device in the supply chain breakroom in the basement.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the surge protector was being used for non-electronic appliances.

Based on observation and interview, it was determined the facility failed to maintain portable med-gas cylinder storage on two of four levels of the component.

Findings include:

1. Observation on March 29, 2022, between 12:15 pm and 1:10 pm, revealed the following;

a. At 12:15 pm, approximatley four E-size oxygen cylinders were laying on the floor in PACU room 2816 on the 2nd floor.

b. At 1:05 pm, approximately 644 cubic feet of oxygen was being stored in the corridor near the EEG Control room on the 1st floor.

c. At 1:10 pm, an unsecured mixed gas E-size cylinder was unsecured in the corridor outside the EEG control room.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed the med-gas cylinder storage defiencies.

Based on observation and interview, it was determined the facility failed to maintain portable oxygen storage on one of five levels of the component.

Findings include:

1. Observation on March 29, 2022, at 10:05 am, revealed portable oxygen cylinders being stored in room 4650 on the fourth floor were not marked as full or empty.

Interview at the time of the exit conference with the Plant Engineering Operations Manager on March 29, 2022, at 3:15 pm, confirmed there was no posted instruction or signage to determined if a cylinder was empty.