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Based on observation and interview, it was determined the facility failed to provide a two-hour fire rated common wall in one instance, affecting four of four floors in this component.

Findings include:

1. Observation on December 7, 2015, at 12:01 PM, revealed the building number 18 electrical room door did not have the required 90 minute fire resistance rating needed for a common wall building separation.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the louvered door installed on the building 18 electrical room did not meet the fire rating needed for a common wall building separation.

Based on observation and interview, it was determined the facility failed to provide the required building construction type, affecting two of two levels in this component.

Findings include:

1. Observation on December 8, 2015, at 9:30 AM, revealed the building lacked complete automatic sprinkler system protection required for a one story, unprotected noncombustible type of construction.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed this unprotected noncombustible building construction requires a complete automatic sprinkler system protection.

Based on observation and interview, it was determined the facility failed to maintain one of over 53 corridor doors in this component.

Findings include:

1. Observation on December 8, 2015, at 9:59AM, revealed the corridor door, serving room 16-14, located in Ward 7, was obstructed from closing by a bed.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the position of the bed would not allow the door to close.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area affecting one of three floors in this component.

Findings include:

1. Observation on December 7, 2015, at 1:05 PM, revealed the third floor records storage area doors, lacked the required self-closing devices.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the doors serving the records storage room did not have self-closing devices installed.

Based on observation and interview, it was determined the facility failed to maintain installed sprinkler system components affecting one of two levels in this component.

Findings include:

1. Observation on December 8, 2015, at 11:09 AM, revealed the main basement entrance corridor had both quick response and standard response sprinkler heads installed in the same compartment.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the basement corridor near the main entrance had mixed response sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain one designated smoking area affecting one of fifteen smoke compartments in this component.

Findings include:

1. Observation on December 8, 2015, at 10:17 AM, revealed numerous discarded cigarette butts mixed with landscaping stones in the outside smoking area adjacent to Ward 6.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the discarded cigarette butts were not properly disposed.

Based on observation and interview, it was determined the facility failed to maintain one medical gas storage location affecting one of fifteen smoke compartments in this component.

Findings include:

1. Observation on December 8, 2015, at 10:48 AM, revealed one unsecured oxygen cylinder in the Ward 4 treatment room number 1053.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the oxygen cylinder was not protected from falling.

Based on observation and interview, it was determined the facility failed to provide a two-hour fire rated common wall in one instance, affecting four of four floors in this component.

Findings include:

1. Observation on December 7, 2015, at 12:01 PM, revealed the building number 18 electrical room door did not have the required 90 minute fire resistance rating needed for a common wall building separation.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the louvered door installed on the building 18 electrical room did not meet the fire rating needed for a common wall building separation.

Based on observation and interview, it was determined the facility failed to provide the required building construction type, affecting two of two levels in this component.

Findings include:

1. Observation on December 8, 2015, at 9:30 AM, revealed the building lacked complete automatic sprinkler system protection required for a one story, unprotected noncombustible type of construction.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed this unprotected noncombustible building construction requires a complete automatic sprinkler system protection.

Based on observation and interview, it was determined the facility failed to maintain one of over 53 corridor doors in this component.

Findings include:

1. Observation on December 8, 2015, at 9:59AM, revealed the corridor door, serving room 16-14, located in Ward 7, was obstructed from closing by a bed.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the position of the bed would not allow the door to close.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area affecting one of three floors in this component.

Findings include:

1. Observation on December 7, 2015, at 1:05 PM, revealed the third floor records storage area doors, lacked the required self-closing devices.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the doors serving the records storage room did not have self-closing devices installed.

Based on observation and interview, it was determined the facility failed to maintain installed sprinkler system components affecting one of two levels in this component.

Findings include:

1. Observation on December 8, 2015, at 11:09 AM, revealed the main basement entrance corridor had both quick response and standard response sprinkler heads installed in the same compartment.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the basement corridor near the main entrance had mixed response sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain one designated smoking area affecting one of fifteen smoke compartments in this component.

Findings include:

1. Observation on December 8, 2015, at 10:17 AM, revealed numerous discarded cigarette butts mixed with landscaping stones in the outside smoking area adjacent to Ward 6.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the discarded cigarette butts were not properly disposed.

Based on observation and interview, it was determined the facility failed to maintain one medical gas storage location affecting one of fifteen smoke compartments in this component.

Findings include:

1. Observation on December 8, 2015, at 10:48 AM, revealed one unsecured oxygen cylinder in the Ward 4 treatment room number 1053.

Exit interview with facility representative #1, maintenance representative #1, maintenance representative #2 and facility fire marshal on December 8, 2015, between 12:00 PM and 12:15 PM, confirmed the oxygen cylinder was not protected from falling.