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Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, on one of seven floors, in accordance with NFPA 220.

Findings include:

Observation of the seventh floor elevator lobby (within the 1929 Building) at 2:13 p.m. on April 4, 2011, revealed a pair of non-rated lifting doors that access the elevator machine penthouse, located beyond the suspended ceiling assembly, which compromise the required two-hour floor slab assembly.

Interview with facility representatives #1 at 2:14 p.m. on April 4, 2011, confirmed the non-rated lifting doors.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one location, on one of seven levels.

Findings include:

Observation of the 1959 Building basement exit access corridor system at 11:22 a.m. on April 6, 2011, revealed several corridor wall penetrations located closest to electrical panel 4L6A.

Interview with facility representatives #1 and #2 at 11:23 a.m. on April 6, 2011, confirmed the corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to construct and maintain five shaft enclosures, on four of seven levels.

Findings include:

1. Observation of various shaft enclosures within this component, between 10:06 a.m. and 11:55 a.m. on April 4, 2011, revealed the below deficiencies:

a. The basement-level elevator pit access door, located within the 1929 Building, lacks a self-closing device. Note: open to the adjacent elevator enclosure. 10:06 a.m.

b. The basement-level elevator pit door lacks the required ninety minute fire resistive labeling. 10:07 a.m.

c. The basement-level condensate return room (shaft initiation/termination point located within) entrance door requires adjustment to fully latch within the corresponding door frame assembly. 10:33 a.m.

d. The basement-level manifold room lacks two-hour fire resistive integrity. Note: this multi-story shaft termination room lacks a north wall; this shaft enclosure is presently "open" to adjacent crawl spaces.

e. The building services/exhaust shaft enclosure is open to all subsequent floors beyond the suspended ceiling assembly within the first floor Snack Bar in the 1929 Building. 10:59 a.m.

f. The portion of the East Wing shaft enclosure located within the second floor Dietary Department requires adjustment to the entrance door in order to fully close and latch within the corresponding door frame assembly. 11:55 a.m.

Interview with facilities representatives #1, between 2:15 p.m. and 2:30 p.m., on April 4, 2011, confirmed the above-listed shaft enclosure discrepancies.

2. Observation of various vertical openings within the Century Building portion of this component, between 11:22 a.m. and 11:44 a.m., on April 5, 2011, revealed the below deficiencies:

a. A large penetration of the floor slab assembly exits between basement and first floor levels, at the base of the medical gas risers. 11:22 a.m.

b. A horizontal penetration of the fourth floor portion of the elevator shaft enclosure was noted within the adjacent 5401 elevator machine room. 11:44 a.m.

Interview with facility representatives #1 and #2, at 11:24 a.m. and 11:45 a.m. on April 5, 2011, confirmed the floor slab penetration, as well as the horizontal penetration of the elevator enclosure wall.

Based on observation and interview, it was determined the facility failed to construct and maintain one smoke barrier separation wall, on one of seven levels.

Findings include:

Observation of the third floor Ladies' Locker Room within the Century Building at 9:06 a.m. on April 8, 2011, revealed the wall to be non-existent toward the rear of the room.

Interview with facility representatives #1 and #2 at 9:07 a.m. on April 8, 2011, confirmed the smoke barrier wall to be lacking in this area.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers, on two of seven levels.

Findings include:

1. Observation of door openings in smoke barriers on April 5, 2011, at 11:00 a.m. revealed a gap greater than one quarter inch between the smoke barrier doors #419136, located in the basement of the Project South Building.

Interview with facility representative #1 on April 5, 2011, at 11:01 a.m. confirmed the smoke door gap.

2. Observation of door openings in smoke barriers on April 6, 2011, at 8:15 a.m. revealed the West smoke doors #419145 located on the fourth floor of the PCT Building, did not close properly.

Interview with facility representative #1 on April 6, 2011, at 8:16 a.m. confirmed the smoke doors would not close.

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

Findings include:

1. Observation of hazardous areas on April 4, 2011, at 1:30 p.m. revealed the third floor N3A Soiled Linen Room walls were not complete.

Interview with facility representative #1 on April 4, 2011, at 1:31 p.m. confirmed the walls were not complete.

2. Observation of hazardous areas on April 6, 2011, between 8:30 a.m. and 9:10 a.m., revealed:

a. 8:30 a.m. - The fourth floor electrical closet located adjacent to pod F had sheetrock pulled away from the wall.

b. 9:00 a.m. - The third floor resident room #352, now being used for storage, lacked a self- closing device on the door.

c. 9:10 a.m. - The third floor corridor closets being used for storage lacked positive latching on the double doors.

Interview with facility representative #1 on April 6, 2011, at 9:11 a.m. confirmed the doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain two exit stair towers.

Findings include:

Observation of various exit stair towers within this component, between 9:15 a.m. on April 4, 2011, and 11:32 a.m. on April 5, 2011, revealed the below deficiencies:

a. Exhaust duct work, which traverses the basement-level portion of the number four stair tower enclosure, 1929 portion of Main Building, lacks two-hour fire resistive enclosure; though the duct work is fire dampered where both entering and exiting the enclosure. 9:15 a.m. on April 4, 2011.

b. The basement-level portion of stair tower number nineteen, within the Century Building, opens directly into the renovation storage room. 11:32 a.m. on April 5, 2011.

Interview with engineering department director during the exit interview process, conducted between 12:05 p.m. and 12:22 p.m. on April 6, 2011, confirmed the duct penetration of the stair tower, as well as the stair tower which opens into the storage occupancy.

Based on observation and interview, it was determined that exit access was not arranged to be accessible at all times, on all seven of seven levels.

Findings include:

1. Observation of means of egress on April 5, 2011, at 11:30 a.m., revealed full-size staff lockers placed within the exit access corridor outside the North elevator on the seventh floor. In addition, cross-corridor doors were placed on both ends of the lockers; rendering this a room. Review of building plans indicate lockers were placed in the same location on all subsequent floors of the facility. Facility to verify through written documentation from engineer that this "room" was not created within a required exit and all travel distances are met.

Interview with facility representative #2, on April 5, 2011, at 11:31 a.m. confirmed the location of the lockers in the exit access corridor.

2. Observation of means of egress on April 6, 2011, at 11:15 a.m. revealed the receiving room, located on the Terrace level, had items stored in front of the doors marked as a required exit.

Interview with facility representative #1, on April 6, 2011, at 11;16 a.m. confirmed the blocked exit.

Based on observation and interview, it was determined the facility failed to install illuminated exit signage, in two locations, on one of seven levels.

Findings include:

Observation of the third floor Century Wing on April 8, 2011, between 8:48 a.m. and 8:52 a.m. revealed the below deficiencies:

a. Additional exit signage is required within one C.C.U. location. 8:48 a.m.

b. Additional exit signage is required within one Medical Transitional Unit location. 8:52 a.m.

Interview with facility representatives #1 and #2 at 8:52 a.m. on April 8, 2011, confirmed the absence of illuminated exit signage in said locations.

Based on observation and interview, it was determined the facility failed to properly install required sprinkler systems in three locations of seven levels.

Findings include:

1. Observation of sprinkler systems on April 4, 2011, at 10:45 a.m. revealed the elevator shafts # 9 and #10, located in building #59 lacked sprinkler coverage.

Interview with facility representative #1 on April 4, 2011, at 10:46 a.m. confirmed the shafts did not have sprinkler coverage.

2. Observation of the the first floor Room 1710 (1929 Building) at 11:14 a.m. on April 4, 2011, revealed the ceiling to have been removed, which requires the installation of upright-style sprinkler heads in lieu of the presently installed surface-mounted sprinkler heads.

3. Observation of the secretary storage closet located on the fourth floor adjacent to room #4119 on April 4, 2011, at 10:45 a.m. had storage items within 18" of the sprinkler head.

Interview with facility representative #2 at 11:15 a.m. and 10:46 a.m. on April 4, 2011, confirmed the presence of surface-mounted heads in lieu of upright-style heads and the storage within 18" of the sprinkler head, respectively.

Based on observation and interview, it was determined the facility failed to properly configure heating, ventilating and air conditioning (HVAC) throughout the building.

Findings include:

1. Observation of the HVAC components on April 4, 2011, at 12:00 PM revealed a flexible duct connector in excess of 14 feet in length, located in the #59 Building, fourth floor equipment room # 4220.

Interview with maintenance representative #1 on April 4, 2011, at 12:01 PM confirmed the duct conector in excess of allowable 14 feet.

2. Observation of various aspects of the heating, ventilation and air conditioning systems within this component between 10:14 a.m. and 11:40 a.m. on April 4, 2011, revealed the below deficiencies:

a. The large exhaust duct located within the basement-level Manifold Room lacks a fire damper where transitioning between shaft wall assembly, which is presently not constructed and cited under deficiency K-20 within this survey, and subsequent crawl spaces. 10:14 a.m.

b. The Manifold Room duct penetration found within the adjacent basement-level exit access corridor system (1929 Building) lacks a fire damper and access panel where penetrating the shaft wall assembly. 10:22 a.m.

c. Two duct penetrations located within the first floor East Wing soiled linen chute termination room lack fire dampers where penetrating enclosure walls. This duct traverses four total stories. 10:40 a.m.

d. The 1959 Wing laundry chute termination room exhaust duct penetrations lack fire dampers where penetrating enclosure walls. This duct traverses four total stories. 10:44 a.m.

e. The 1929 Wing building services/exhaust shaft enclosure duct work (first identified within the first floor Snack Bar) lacks fire dampers, retaining angles, and access panels within both the second floor oxygen storage room and adjacent Physician's Office. 11:40 a.m. This shaft enclosure lacks fire dampers, retaining angles, and access panels at all subsequent levels which was noted throughout the course of this survey.

Interview with engineering department director during the exit interview process conducted between 12:05 p.m. and 12:22 p.m. on April 6, 2011, confirmed the above heating, ventilation, and air conditioning discrepancies.

3. Observation of various aspects of the heating, ventilation, and air conditioning systems between 9:15 a.m. and 9:32 a.m. on April 5, 2011, revealed the below deficiencies:

a. Flex duct connectors located within the sixth floor four-bank elevator lobby was noted to be in excess of 14 feet in length. 9:15 a.m.

b. Duct work found within the fifth floor Room 516 lacks fire dampers at the fifth and sixth floor levels where penetrating the floor slab assemblies. 9:32 a.m.

Interview with facilities representative #1 at 9:16 a.m. and 9:33 a.m. respectively, confirmed the flex duct connector in excess of 14 feet and the duct work to lack fire dampers.

4. Observation of the 1959 Building basement at 11:29 a.m. on April 6, 2011, revealed a length of flex duct connector in excess of 80 feet in length within the back housekeeping exit access corridor.

Interview with facility representative #1 and #2 11:30 a.m. on April 6, 2011, confirmed the existence of flex duct connector in excess of 14 feet in length.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage areas in one instance on one of seven levels.

Findings include:

Observation of medical gas storage areas on April 5, 2011, at 8:00 a.m. revealed the South nitrogen storage room, located on the second floor, lacked the required ventilation to the outside; either from a dedicated mechanical ventilation system or by natural venting from a vent opening, with a minimum of 72 square inches in total free area.

Interview with facility representative #1 on April 5, 2011, at 8:01 a.m. confirmed the room lacked ventilation.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system on three of seven levels.

Findings include:

1. Observation of the sixth floor exit access corridor system located closest to the 6001 smoke barrier separation wall on April 5, 2011, at 8:22 a.m. revealed medical gas piping to reside atop dissimilar metal.

Interview with facility representatives #1 and #2 at 8:23 a.m. on April 5, 2011, confirmed the medical gas piping to reside atop dissimilar metal.

2. Observation of various aspects of the piped-in medical gas systems within this component, between 8:33 a.m. and 11:07 a.m. on April 6, 2011, revealed the below deficiencies:

a.. Oxygen, vacuum, and medical air shutoff valves are located within the same area as serviced within the fourth floor N.I.C.U. in the Century Building at 8:33 a.m. NFPA 56F, 1977 edition, Section #424 as well as NFPA 1999, 1999 edition, Section 4-3.1.2.3(d)

b. Miscellaneous wiring is affixed to oxygen piping within the 1959 Building basement. (closest to the I.W. Room) 11:07 a.m.

Interview with facility representatives #1 and #2 at 8:34 a.m. and 11:08 a.m., respectively, on April 6, 2011, confirmed the shutoff valves located within the fourth floor N.I.C.U. and the wiring affixed to medical gas piping within the basement-level exit access corridor.

Based on observation and interview, it was determined the facility failed to maintain electrical components in one location, out of seven levels, in accordance with NFPA 70.

Findings include:

Observation of the first floor compressor room (within the 1929 Building) at 10:59 a.m. on April 4, 2011, revealed an extension cord in use in this area.

Interview with facility representative one at 11:00 a.m. on April 4, 2011, confirmed the extension cord usage.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, on one of seven floors, in accordance with NFPA 220.

Findings include:

Observation of the seventh floor elevator lobby (within the 1929 Building) at 2:13 p.m. on April 4, 2011, revealed a pair of non-rated lifting doors that access the elevator machine penthouse, located beyond the suspended ceiling assembly, which compromise the required two-hour floor slab assembly.

Interview with facility representatives #1 at 2:14 p.m. on April 4, 2011, confirmed the non-rated lifting doors.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one location, on one of seven levels.

Findings include:

Observation of the 1959 Building basement exit access corridor system at 11:22 a.m. on April 6, 2011, revealed several corridor wall penetrations located closest to electrical panel 4L6A.

Interview with facility representatives #1 and #2 at 11:23 a.m. on April 6, 2011, confirmed the corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to construct and maintain five shaft enclosures, on four of seven levels.

Findings include:

1. Observation of various shaft enclosures within this component, between 10:06 a.m. and 11:55 a.m. on April 4, 2011, revealed the below deficiencies:

a. The basement-level elevator pit access door, located within the 1929 Building, lacks a self-closing device. Note: open to the adjacent elevator enclosure. 10:06 a.m.

b. The basement-level elevator pit door lacks the required ninety minute fire resistive labeling. 10:07 a.m.

c. The basement-level condensate return room (shaft initiation/termination point located within) entrance door requires adjustment to fully latch within the corresponding door frame assembly. 10:33 a.m.

d. The basement-level manifold room lacks two-hour fire resistive integrity. Note: this multi-story shaft termination room lacks a north wall; this shaft enclosure is presently "open" to adjacent crawl spaces.

e. The building services/exhaust shaft enclosure is open to all subsequent floors beyond the suspended ceiling assembly within the first floor Snack Bar in the 1929 Building. 10:59 a.m.

f. The portion of the East Wing shaft enclosure located within the second floor Dietary Department requires adjustment to the entrance door in order to fully close and latch within the corresponding door frame assembly. 11:55 a.m.

Interview with facilities representatives #1, between 2:15 p.m. and 2:30 p.m., on April 4, 2011, confirmed the above-listed shaft enclosure discrepancies.

2. Observation of various vertical openings within the Century Building portion of this component, between 11:22 a.m. and 11:44 a.m., on April 5, 2011, revealed the below deficiencies:

a. A large penetration of the floor slab assembly exits between basement and first floor levels, at the base of the medical gas risers. 11:22 a.m.

b. A horizontal penetration of the fourth floor portion of the elevator shaft enclosure was noted within the adjacent 5401 elevator machine room. 11:44 a.m.

Interview with facility representatives #1 and #2, at 11:24 a.m. and 11:45 a.m. on April 5, 2011, confirmed the floor slab penetration, as well as the horizontal penetration of the elevator enclosure wall.

Based on observation and interview, it was determined the facility failed to construct and maintain one smoke barrier separation wall, on one of seven levels.

Findings include:

Observation of the third floor Ladies' Locker Room within the Century Building at 9:06 a.m. on April 8, 2011, revealed the wall to be non-existent toward the rear of the room.

Interview with facility representatives #1 and #2 at 9:07 a.m. on April 8, 2011, confirmed the smoke barrier wall to be lacking in this area.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers, on two of seven levels.

Findings include:

1. Observation of door openings in smoke barriers on April 5, 2011, at 11:00 a.m. revealed a gap greater than one quarter inch between the smoke barrier doors #419136, located in the basement of the Project South Building.

Interview with facility representative #1 on April 5, 2011, at 11:01 a.m. confirmed the smoke door gap.

2. Observation of door openings in smoke barriers on April 6, 2011, at 8:15 a.m. revealed the West smoke doors #419145 located on the fourth floor of the PCT Building, did not close properly.

Interview with facility representative #1 on April 6, 2011, at 8:16 a.m. confirmed the smoke doors would not close.

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

Findings include:

1. Observation of hazardous areas on April 4, 2011, at 1:30 p.m. revealed the third floor N3A Soiled Linen Room walls were not complete.

Interview with facility representative #1 on April 4, 2011, at 1:31 p.m. confirmed the walls were not complete.

2. Observation of hazardous areas on April 6, 2011, between 8:30 a.m. and 9:10 a.m., revealed:

a. 8:30 a.m. - The fourth floor electrical closet located adjacent to pod F had sheetrock pulled away from the wall.

b. 9:00 a.m. - The third floor resident room #352, now being used for storage, lacked a self- closing device on the door.

c. 9:10 a.m. - The third floor corridor closets being used for storage lacked positive latching on the double doors.

Interview with facility representative #1 on April 6, 2011, at 9:11 a.m. confirmed the doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain two exit stair towers.

Findings include:

Observation of various exit stair towers within this component, between 9:15 a.m. on April 4, 2011, and 11:32 a.m. on April 5, 2011, revealed the below deficiencies:

a. Exhaust duct work, which traverses the basement-level portion of the number four stair tower enclosure, 1929 portion of Main Building, lacks two-hour fire resistive enclosure; though the duct work is fire dampered where both entering and exiting the enclosure. 9:15 a.m. on April 4, 2011.

b. The basement-level portion of stair tower number nineteen, within the Century Building, opens directly into the renovation storage room. 11:32 a.m. on April 5, 2011.

Interview with engineering department director during the exit interview process, conducted between 12:05 p.m. and 12:22 p.m. on April 6, 2011, confirmed the duct penetration of the stair tower, as well as the stair tower which opens into the storage occupancy.

Based on observation and interview, it was determined that exit access was not arranged to be accessible at all times, on all seven of seven levels.

Findings include:

1. Observation of means of egress on April 5, 2011, at 11:30 a.m., revealed full-size staff lockers placed within the exit access corridor outside the North elevator on the seventh floor. In addition, cross-corridor doors were placed on both ends of the lockers; rendering this a room. Review of building plans indicate lockers were placed in the same location on all subsequent floors of the facility. Facility to verify through written documentation from engineer that this "room" was not created within a required exit and all travel distances are met.

Interview with facility representative #2, on April 5, 2011, at 11:31 a.m. confirmed the location of the lockers in the exit access corridor.

2. Observation of means of egress on April 6, 2011, at 11:15 a.m. revealed the receiving room, located on the Terrace level, had items stored in front of the doors marked as a required exit.

Interview with facility representative #1, on April 6, 2011, at 11;16 a.m. confirmed the blocked exit.

Based on observation and interview, it was determined the facility failed to install illuminated exit signage, in two locations, on one of seven levels.

Findings include:

Observation of the third floor Century Wing on April 8, 2011, between 8:48 a.m. and 8:52 a.m. revealed the below deficiencies:

a. Additional exit signage is required within one C.C.U. location. 8:48 a.m.

b. Additional exit signage is required within one Medical Transitional Unit location. 8:52 a.m.

Interview with facility representatives #1 and #2 at 8:52 a.m. on April 8, 2011, confirmed the absence of illuminated exit signage in said locations.

Based on observation and interview, it was determined the facility failed to properly install required sprinkler systems in three locations of seven levels.

Findings include:

1. Observation of sprinkler systems on April 4, 2011, at 10:45 a.m. revealed the elevator shafts # 9 and #10, located in building #59 lacked sprinkler coverage.

Interview with facility representative #1 on April 4, 2011, at 10:46 a.m. confirmed the shafts did not have sprinkler coverage.

2. Observation of the the first floor Room 1710 (1929 Building) at 11:14 a.m. on April 4, 2011, revealed the ceiling to have been removed, which requires the installation of upright-style sprinkler heads in lieu of the presently installed surface-mounted sprinkler heads.

3. Observation of the secretary storage closet located on the fourth floor adjacent to room #4119 on April 4, 2011, at 10:45 a.m. had storage items within 18" of the sprinkler head.

Interview with facility representative #2 at 11:15 a.m. and 10:46 a.m. on April 4, 2011, confirmed the presence of surface-mounted heads in lieu of upright-style heads and the storage within 18" of the sprinkler head, respectively.

Based on observation and interview, it was determined the facility failed to properly configure heating, ventilating and air conditioning (HVAC) throughout the building.

Findings include:

1. Observation of the HVAC components on April 4, 2011, at 12:00 PM revealed a flexible duct connector in excess of 14 feet in length, located in the #59 Building, fourth floor equipment room # 4220.

Interview with maintenance representative #1 on April 4, 2011, at 12:01 PM confirmed the duct conector in excess of allowable 14 feet.

2. Observation of various aspects of the heating, ventilation and air conditioning systems within this component between 10:14 a.m. and 11:40 a.m. on April 4, 2011, revealed the below deficiencies:

a. The large exhaust duct located within the basement-level Manifold Room lacks a fire damper where transitioning between shaft wall assembly, which is presently not constructed and cited under deficiency K-20 within this survey, and subsequent crawl spaces. 10:14 a.m.

b. The Manifold Room duct penetration found within the adjacent basement-level exit access corridor system (1929 Building) lacks a fire damper and access panel where penetrating the shaft wall assembly. 10:22 a.m.

c. Two duct penetrations located within the first floor East Wing soiled linen chute termination room lack fire dampers where penetrating enclosure walls. This duct traverses four total stories. 10:40 a.m.

d. The 1959 Wing laundry chute termination room exhaust duct penetrations lack fire dampers where penetrating enclosure walls. This duct traverses four total stories. 10:44 a.m.

e. The 1929 Wing building services/exhaust shaft enclosure duct work (first identified within the first floor Snack Bar) lacks fire dampers, retaining angles, and access panels within both the second floor oxygen storage room and adjacent Physician's Office. 11:40 a.m. This shaft enclosure lacks fire dampers, retaining angles, and access panels at all subsequent levels which was noted throughout the course of this survey.

Interview with engineering department director during the exit interview process conducted between 12:05 p.m. and 12:22 p.m. on April 6, 2011, confirmed the above heating, ventilation, and air conditioning discrepancies.

3. Observation of various aspects of the heating, ventilation, and air conditioning systems between 9:15 a.m. and 9:32 a.m. on April 5, 2011, revealed the below deficiencies:

a. Flex duct connectors located within the sixth floor four-bank elevator lobby was noted to be in excess of 14 feet in length. 9:15 a.m.

b. Duct work found within the fifth floor Room 516 lacks fire dampers at the fifth and sixth floor levels where penetrating the floor slab assemblies. 9:32 a.m.

Interview with facilities representative #1 at 9:16 a.m. and 9:33 a.m. respectively, confirmed the flex duct connector in excess of 14 feet and the duct work to lack fire dampers.

4. Observation of the 1959 Building basement at 11:29 a.m. on April 6, 2011, revealed a length of flex duct connector in excess of 80 feet in length within the back housekeeping exit access corridor.

Interview with facility representative #1 and #2 11:30 a.m. on April 6, 2011, confirmed the existence of flex duct connector in excess of 14 feet in length.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage areas in one instance on one of seven levels.

Findings include:

Observation of medical gas storage areas on April 5, 2011, at 8:00 a.m. revealed the South nitrogen storage room, located on the second floor, lacked the required ventilation to the outside; either from a dedicated mechanical ventilation system or by natural venting from a vent opening, with a minimum of 72 square inches in total free area.

Interview with facility representative #1 on April 5, 2011, at 8:01 a.m. confirmed the room lacked ventilation.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system on three of seven levels.

Findings include:

1. Observation of the sixth floor exit access corridor system located closest to the 6001 smoke barrier separation wall on April 5, 2011, at 8:22 a.m. revealed medical gas piping to reside atop dissimilar metal.

Interview with facility representatives #1 and #2 at 8:23 a.m. on April 5, 2011, confirmed the medical gas piping to reside atop dissimilar metal.

2. Observation of various aspects of the piped-in medical gas systems within this component, between 8:33 a.m. and 11:07 a.m. on April 6, 2011, revealed the below deficiencies:

a.. Oxygen, vacuum, and medical air shutoff valves are located within the same area as serviced within the fourth floor N.I.C.U. in the Century Building at 8:33 a.m. NFPA 56F, 1977 edition, Section #424 as well as NFPA 1999, 1999 edition, Section 4-3.1.2.3(d)

b. Miscellaneous wiring is affixed to oxygen piping within the 1959 Building basement. (closest to the I.W. Room) 11:07 a.m.

Interview with facility representatives #1 and #2 at 8:34 a.m. and 11:08 a.m., respectively, on April 6, 2011, confirmed the shutoff valves located within the fourth floor N.I.C.U. and the wiring affixed to medical gas piping within the basement-level exit access corridor.

Based on observation and interview, it was determined the facility failed to maintain electrical components in one location, out of seven levels, in accordance with NFPA 70.

Findings include:

Observation of the first floor compressor room (within the 1929 Building) at 10:59 a.m. on April 4, 2011, revealed an extension cord in use in this area.

Interview with facility representative one at 11:00 a.m. on April 4, 2011, confirmed the extension cord usage.