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Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the building construction in one instance within this component.

Findings include:

Observation made on June 27, 2012, at 1:20 p.m., revealed that inside the first floor admission department (patient belonging closet) back wall, had a horizontal structural steel beam which lacks fire proofing material on the bottom.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the missing required fire proofing.

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Observation made on September 10, 2012, at 11:30 a.m., during a revisit, revealed that work was not completed.

Interview with Director of Plant Operation on September 10, 2012, at 12:30 p.m. at the exit conference, confirmed that work was not completed.

Based on observation and interview, it was determined that the facility failed to maintain smoke barriers in two instances within this facility.

Findings include:

Observation made on June 27, 2012, between 10:55 a.m. and 11:04 a.m., revealed that the following smoke barrier walls had unsealed horizontal penetrations:

a. 10:55 a.m., the first floor smoke barrier above the door at Room 136 was not complete to the ceiling above; and
b.11:04 a.m., inside first floor Room117 with data wiring.(COMPLETED).

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the above unsealed penetrations in the smoke barrier wall.

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Observation made on September 10, 2012, at 9:35 a.m., during a revisit, revealed that item(a) was not corrected.

Interview with Director of Plant Operation on September 10, 2012, at 12:30 p.m. at the exit conference, confirmed that work was not completed.

Based on observation and interview, it was determined that the facility failed to ensure that heating, air conditioning, and ventilating systems are installed properly and penetrations are protected in two instances within this component.

Findings include:

1. Observation made on June 27, 2012 at 1:44 p.m., revealed that on the ground level mechanical room closet #1, there was a large gap where the duct work penetrates the exterior cinder block wall into the building which is not smoke tight and exposes the interior of the building areas. ( COMPLETED).

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed the penetration of the wall by the ductwork.

2. Observation made on June 27, 2012, at 9:35 a.m., that the fire damper above the smoke barrier doors located on the second floor at Room 213, appears to be tied in the open position by the fusible link that is attached.

Interview with the Administrator and Director of Plant Operation on June 27, 2012, at 3:00 p.m., at the exit conference, confirmed that the fire damper was not maintained properly.
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Observation made on September 10, 2012, at 11:30 a.m., during a revisit, revealed that item # 2, was not corrected.

Interview with Director of Plant Operation on September 10, 2012, at 12:30 p.m. at the exit conference, confirmed that work was not completed.