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Based on observation and interview, it was determined the facility failed to maintain common walls on three of eight floors within this component.

Findings include:

A. Observation of common walls on March 20, 2012, between 7:42 AM and 2:00 PM revealed:

1. 7:42 AM - The 5th floor (facility 4th floor) common wall doors leading to the Trexler Building revealed the doors were misaligned approximately eight feet to the East of the common wall.

2. 10:55 AM - The 5th floor (facility 4th floor) common wall doors leading to the 451 Medical Plaza walkway lacked a door coordinator which would allow the doors to close properly.

3. 11:00 AM - The 5th floor (facility 4th floor) common wall at GI holding had a spray foam being used to seal penetrations. Facility must verify through documentation the foam is not combustible in nature or flammable, or remove the foam.

4. 12:25 PM - The 4th floor (facility 3rd floor) common wall located in the Service Wing room #T315 had unsealed penetrations.

5. 12:55 PM - The 4th floor (facility 3rd floor) common wall doors leading to the Trexler Building revealed the doors were misaligned approximately four feet to the West of the common wall.

B. Observation of common walls on March 21, 2011, between 7:15 AM and 8:28 AM revealed:

1. 7:15 AM - The 3rd floor (facility 2nd floor) doors leading to the Trexler Building had a gap greater than a quarter inch between the doors when closed.

2. 7:30 AM - The 3rd floor (facility 2nd floor) doors located in Moss Rehab lacked a door coordinator which would allow the doors to close properly.

3. 8:28 AM - The 2nd floor (facility 1st floor) doors located at Radiology Holding area could not close and latch properly.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the common wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations throughout this component.

Findings include:

Observation of building construction on March 21, 2012, between 10:00 AM and 1:30 PM revealed the component exceeds maximum allowable story height for this type of construction.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the component exceeds the maximum allowable story height and identified the facility has an acceptable Fire Safety Evaluation System (FSES) reviewed on March 21, 2012, addressing this issue.

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

Findings include:

A. Observation of corridor doors on March 20, 2012, between 8:49 AM and 8:50 AM revealed:

1. 8:49 AM - The resident room door to the 6th floor (facility 5th floor) resident room #546 could not close properly, due to an isolation box hanging from the top of the door.

2. 8:50 AM - - The resident room door to the 6th floor (facility 5th floor) resident room #545 could not close properly, due to an isolation box hanging from the top of the door.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the doors could not close.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical openings within this component.

Findings include:

Observation of vertical openings on March 21, 2012, revealed unprotected structural steel located within the shaft enclosures.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the unprotected structural steel and identified the facility has an acceptable Fire Safety Evaluation System (F.S.E.S.) reviewed on March 21, 2012, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas on one of five floors in the component.

Findings include:

A. Observation of hazardous areas on March 21, 2012, between 9:40 AM and 9:45 AM revealed:

1. 9:40 AM - The 3rd floor (facility 2nd floor) Storage Room #8 lacked a self closing device on the door.

2. 9:45 AM - The 2nd floor (facility 1st floor) EKG File Storage Room lacked a self closing device on the door.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the doors lacked a self closing device.

Based on observation and interview the facility failed to properly maintain one of three exit stair towers in this component.

Findings include:

Observation of exit stair towers on March 21, 2012, at 9:15 AM revealed a trash can being stored in the 5th floor (facility 4th floor) Cath Lab exit stair tower.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the trash can in an exit stair tower.

Based on observation and interview, it was determined the facility failed to ensure that exit access corridors were maintained clear and unobstructed on two of eight floors in the component.

Findings include:

A. Observation of exit access corridors on March 21, 2012, between 7:45 AM and 9:05 AM revealed:

1. 7:45 AM - The 2nd floor (facility 1st floor) Physicians Entrance had a desk placed in the corridor.

2. 8:35 AM - The 1st floor (facility ground floor) corridor near the Tower elevators had storage of items including SPD equipment, and shelf units.

3. 9:05 AM - The 1st floor (facility ground floor) corridor near the Plumbing Shop had storage of items including boxes, and carts.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the items stored in the corridor.

Based on documentation review and interview, it was determined the facility did not have adequate documentation to support the required semi-annual inspection of the fire alarm system in this facility.

Findings include:

Observation of fire alarm documentation on March 19, 2012, at 11:00 AM revealed the Simplex-Grinell Fire Alarm Report dated 11-16-2010 had deficiencies including devices which could not be accessed. Current reports dated from 1-14-2011 to present, performed by Grant Facility Management staff show no deficiencies. There is no documentation to verify corrections of previous report deficiencies. Facility to provide documentation verifying service personnel conducting fire alarm testing are qualified and experienced in accordance with NFPA 72, 1999 edition.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the fire alarm report deficiency.

Based on observation and interview it was determined the facility failed to maintain smoke detectors on one of five floors in the component.

Findings include:

Observation of installed smoke detectors on March 21, 2012, revealed the smoke detectors located on the 4th floor (facility 3rd floor) Sleep Lab were installed close to an HVAC diffusers. Facility is to verify air movement from the diffusers is not interfering with the operation of the smoke detectors.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the location of the smoke detectors.

Based on observation and interview it was determined the facility failed to maintain portable fire extinguishers on one of eight floors in the component.

Findings include:

A. Observation of fire extinguishers on March 21, 2012, between 7:58 AM and 8:20 AM revealed:

1. 7:58 AM - A fire extinguisher located in the 2nd floor (facility 1st floor) Telecom Room was placed on the floor.

2. 8:20 AM - A fire extinguisher located in the 2nd floor (facility 1st floor) MRI Equipment room was placed on the floor.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the fire extinguisher deficiencies.

Based on observation and interview it was determined the facility failed to properly configure heating, ventilating and air conditioning (HVAC) components on two of eight floors in the component..

Findings include:

A. Observation of HVAC components on March 20, 2012, between 7:30 AM and 8:30 AM revealed:

1. 7:30 AM - A flexible duct connector in excess of 14 feet in length was located on the 7th floor (facility 6th floor) corridor near the Nurses Station.

2. 8:30 AM - A flexible duct connector in excess of 14 feet in length was located on the 6th floor (facility 5th floor) corridor near the Nurses Station.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the confirmed the flex duct.

Based on observation and interview it was determined the facility failed to properly store medical gas cylinders on one of eight floors in the component.

Findings include:

Observation of medical gas storage on March 19, 2012, at 2:15 PM revealed an unsecured "E" sized oxygen cylinder lying on the floor, located on the 8th floor (facility 7th floor) Equipment room #7014.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the unsecured cylinder.

Based on observation and interview it was determined the facility failed to maintain generators in one instance in the facility.

Findings include:

Observation of the generator annunciators on March 21, 2012, at 8:00 AM revealed only two of the five generator annunciators were located at the 2nd floor (facility 1st floor) Telecom Room. Three remaining annunciators were not located.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the generator annunciators were not located.

Based on observation and interview it was determined the facility failed to maintain electrical wiring and equipment on one of eight floors in the component.

Findings include:

A. Observation of electrical wiring and equipment on March 20, 2012, at 2:20 PM revealed a refrigerator, and microwave plugged into a surge suppressor power strip located on the 8th floor (facility 7th floor) Respiratory Office #7010.

B. Observation of electrical wiring and equipment on March 20, 2012, between 7:10 AM and 8:45 AM revealed:

1. 7:10 AM - The 7th floor (facility 6th floor) Dialysis Room #618 had patient care items plugged into a surge suppressor power strip.

2. 8:45 AM - The 6th floor (facility 5th floor) Clean Utility room had a refrigerator plugged into a surge suppressor power strip.

Exit interview with Facility Management Director on March 21, 2012, between 11:00 AM and 11:30 AM confirmed the unauthorized use of a surge suppressor power strips.