HospitalInspections.org

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

Findings include:

1. Observation on December 14, 2023, at 11:40 a.m., revealed the Unit 311, Visiting Room door required adjustment to fully latch within the door frame assembly.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the common wall door deficiency.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors within this component.

Findings include:

1. Observation on December 14, 2023, between 11:30 a.m., and 1:15 p.m., revealed this component exceeded the maximum allowable story height for this type of construction.

Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed this component exceeded the maximum allowable story height for this type of construction.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors within this component.

Findings include:

1. Observation on December 14, 2023, between 8:30 a.m., and 11:30 a.m., revealed this component exceeded the maximum allowable story height for this type of construction.

Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed this component exceeded the maximum allowable story height for this type of construction.

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

Findings include:

1. Observation on December 14, 2023, at 12:44 p.m., revealed the Unit 214, door 2055, stair tower enclosure door was not fire-tight.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the stair tower deficiency.

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

Findings include:

1. Observation on December 14, 2023, at 9:14 a.m., revealed exit signage had been removed from the second floor, Unit 214 construction area.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the exit signage deficiency.

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

Findings include:

1. Observation on December 14, 2023, at 11:50 a.m, revealed a vertical penetration of the floor slab assembly, located within the 310 Unit, Room 1244.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the vertical opening deficiency.

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

Findings include:

1. Observation on December 14, 2023, between 10:23 a.m., and 10:42 a.m., revealed the following:

a. 10:23 a.m., a penetration of the floor slab assembly, located within the third floor room, closest to stair tower door 3072.
b. 10:40 a.m., at the floor slab assembly, located within the Unit 209 Shower Room.
c. 10:42 a.m., an unprotected, three story, vertical opening, located within the Unit 209 Shower Room.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the vertical opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 9:02 a.m., revealed the Unit 211, Room 1100F, Janitor's Closet door lacked a self-closing device.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the hazardous area enclosure deficiency.

Based on observation and interview, it was determined the facility failed to install automatic sprinkler protection in one location, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 8:37 a.m., revealed the Unit 211, electrical closet, lacked automatic sprinkler protection.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed automatic sprinkler protection deficiency.

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

Findings include:

1. Observation on December 14, 2023, between 9:31 a.m., and 10:10 a.m., revealed penetrations of the smoke barrier separation walls in the following locations:

a. 9:31 a.m., within the second floor, Unit 213, above the 2016 door.
b. 10:10 a.m., above third floor, smoke barrier door 3300.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation wall deficiencies.

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

Findings include:

1. Observation on December 14, 2023, at 9:22 a.m., revealed the 2200A, smoke barrier separation door, was lacking a portion of the self-closing assembly.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation door deficiency.

Based on observation and interview, it was determined the facility failed to maintain the heating, ventilation, and air conditioning system in one location, affecting two of four floors.

Findings include:

1. Observation on December 14, 2023, at 8:45 a.m., revealed a fresh air duct penetration of the floor slab assembly, located within the first floor, Unit 211, Room 1100C, lacked retaining angles and a fire damper.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the HVAC deficiency.