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Based on observation and interview, it was determined the facility failed to maintain exit corridor walls in 15 of 24 smoke compartments within the component.

Findings include:

1. Observation on January 26-27, 2015, between 7:15 AM and 3:00 PM revealed numerous unprotected penetrations in exit corridor walls on all levels, caused by the heating, ventilation and air conditioning (HVAC) system.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the unprotected penetrations in exit corridor walls on all levels caused by "open return plenums" used extensively throughout the construction of the original building. The facility identified that it has an acceptable FSES reviewed on January 27, 2015, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain exit corridor walls affecting 5 of 5 floors within the component.

Findings include:

1. Observation on January 26-27, 2015, between 7:15 AM and 3:00 PM revealed the following elevator shaft enclosures had unprotected structural steel:

a. D-Elevator, unprotected structural steel embedded in the enclosure on all floors.

b. Dietary Elevator, unprotected structural steel embedded in the enclosure on all floors.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the elevator enclosures had unprotected structural steel and identified the facility has an acceptable FSES reviewed on January 27, 2015, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating in three instances affecting 6 of 24 smoke compartments within the component.

Findings include:

1. Observation on January 26, 2015, between 10:45 AM and 2:30 PM revealed the smoke barrier walls were not complete to the outside wall in the following locations:

a. 10:45 AM - Third floor, room #390.

b. 1:00 PM - Second floor, Same Day Services, room #1

c. 2:30 PM - First floor, Work Center, File Storage room.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the incomplete smoke barrier walls.

Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier doors, affecting 2 of 24 smoke compartments within the component.
Findings include:

1. Observation on January 26, 2015, at 10:50 AM revealed the fourth floor smoke barrier door located at the Nurse Family Partnership, lacked a self-closing device.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the door lacked a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in two instances affecting 2 of 24 smoke compartments within the component.

Findings include:

1. Observation on January 26, 2015, between 12:25 PM and 2:35 PM revealed the following rooms were not configured for storage:

a. 12:25 PM - The 3rd floor Clinical Office closet.

b. 2:35 PM - The 1st floor Work Center Conference room, now a file storage room.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the rooms were not configured as hazardous areas.

Based on observation and interview, it was determined that exit access is not arranged to be accessible at all times at two instances at the facility.

Findings include:

1. Observation on January 26, 2015, at 2:00 PM revealed the exit discharge sidewalks were snow covered outside the back exit of the Cancer Center.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the snow covered sidewalks.

2. Observation on January 27, 2015, at 8:00 AM revealed the exit discharge sidewalks were snow covered outside the " Old Chapel " .

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the snow covered exit discharges.

Based on observation and interview it was determined the facility failed to maintain portable fire extinguishers in 1 of 24 smoke compartments within the component.

Findings include:

1. Observation on January 26, 2015, at 9:50 AM revealed the fire extinguisher located in the 5th floor, HC8 Mechanical room was unsecured on the floor.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the unsecured fire extinguisher.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one instance in 1 of 24 smoke compartments within the component.

Findings include:

1. Observation on January 26, 2015, at 10:35 AM revealed medical gas piping throughout the 4th floor Sleep Center corridor was not labeled.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the medical gas piping was not labeled.

Based on observation and interview, it was determined the facility failed to maintain the installed electrical distribution system in three instances within the component.

Findings include:

1. Observation on January 26, 2015, between 8:45 AM and 12:35 PM revealed:

a. 8:45 AM - Penthouse #6 had exposed electrical wires which were not terminated or removed.

b. 10:00 AM - The fifth floor corridor, outside the IT Training Classroom had a microwave oven and a toaster plugged into a surge suppressor power strip.

c. 12:35 PM - The 3rd floor Sleeping room, located in the Family room, had a bed placed against an electrical receptacle.

Exit interview with facility representatives #1, #2, #3, and #4, on January 27, 2015, between 9:30 AM and 9:45 AM confirmed the exposed electrical wires, unauthorized use of a surge suppressor power strip, and the bed against a receptacle.