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Tag No.: K0161
Based on observation and interview, it was determined the facility exceeded maximum allowable story height for this type of construction.
Findings include:
1. Observation on April 30, 2024, at 10:45 am, revealed the facility exceeded the maximum allowable story height for a three story, Type II (000), unprotected, noncombustible building.
Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the facility exceeds maximum allowable story height for this type of construction.
Tag No.: K0225
Based on observation and interview, it was determined the facility failed to maintain the required fire rating of stair tower doors on one of three floors.
Findings include:
1. Observation on April 30, 2024, at 12:14 pm, revealed the stair tower door at the E.R. failed to latch in the corresponding frame when tested.
Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the lacked positive latching.
Tag No.: K0321
Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas on one of three floors.
Findings include:
1. Observation on April 30, 2024, at 12:11 pm, revealed the door to the mechanical room failed to latch in the frame when tested.
Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the door lacked positive latching.
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to maintain the required fire resistance of smoke barrier walls in one location affecting two of four smoke compartments.
Findings include:
1. Observation on April 30, 2024, at 11:53 am, revealed an unsealed cable penetration of the 2nd floor smoke barrier wall in room 209.
Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the wiring penetration was not sealed.
Tag No.: K0908
Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one of four smoke compartments.
Findings include:
1. Observation on April 30, 2024, at 12:02 pm, revealed the medical gas lines were in contact with galvanized conduit and MC cables in several locations above the ceiling outside the O.R. on the 2nd floor.
Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the copper medical gas lines were in contact with dissimilar metals.