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Based on observation and interview, it was determined the facility failed to properly maintain two-hour fire rated common walls on one of nine floors in this component.

Findings include:

Observation on May 8, 2012, at 10:51 AM, revealed the First floor (facility ground floor) double set of doors, serving the 2-hour fire rated common wall located at the Ancillary building, did not provide positive latching on the left leaf.

Exit interview with maintenance representative #1, and facility administrator on May 8, 2012, between 11:30 AM and 11:45 AM, confirmed the left leaf of the ground floor double set of doors did not properly latch due to warping caused by humidity.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier doors affecting three of five smoke compartments on one of nine floors in this component.

Findings include:

A. Observation on May 7, 2012, between 12:30 PM and 12:40 PM, of smoke barrier doors revealed the following:

1. 12:30 PM - Fifth floor (facility fourth floor), north corridor, double set of doors serving the smoke barrier had a one quarter inch gap between the meeting edges when closed.

2. 12:40 PM - Fifth floor (facility fourth floor), south corridor, double set of doors serving the smoke barrier had a one quarter inch gap between the meeting edges when closed.

Exit interview with maintenance representative #1, and facility administrator on May 8, 2012, between 11:30 AM and 11:45 AM, confirmed these smoke barrier doors did not provide smoke tight integrity.

Based on observation and interview, it was determined the facility failed to properly maintain hazardous areas on three of nine floors in this component.

Findings include:

A. Observation on May 7, 2012, between 11:23 AM and 12:47 PM, of hazardous areas revealed the following:

1. 11:23 AM - Sixth floor (facility fifth floor), pharmacy satellite office, a hazardous area used to store a large quantity of combustible paper suppllies, corridor door requires a self-closing device.

2. 11:59 AM - Fifth floor (facility fourth floor), pharmacy satellite office, a hazardous area used to store a large quantity of combustible paper supplies, corridor door requires a self-closing device.

3. 12:47 PM - Fourth floor (facility third floor), post partum equipment room, a hazardous area used to store a large quantity of combustible paper supplies, corridor door requires a self-closing device.

Exit interview with maintenance representative #1, and facility administrator on May 8, 2012, between 11:30 AM and 11:45 AM, confirmed the doors lacked self-closing devices.

B. Observation on May 8, 2012, at 10:43 AM, revealed the 1959 basement IT storage room, a hazardous area used to store combustible boxes, corridor door requires a self-closing device.

Exit interview with maintenance representative #1, and facility administrator on May 8, 2012, between 11:30 AM and 11:45 AM, confirmed the door lacked a self-closing device.

Based on observation and interview, it was determined the facility failed to properly configure the piped-in medical gas distribution system on one of nine floors in this component.

Findings include:

A. Observation on May 8, 2012, between 9:30 AM and 10:00 AM, of the medical gas piping revealed the following:

1. 9:30 AM - First floor (facility ground floor) employee locker room, main east tower medical gas piping lacks required shut-off valves at the base of vertical risers.

2. 9:40 AM - First floor (facility ground floor) Emergency Department suite A, has medical gas zone valves improperly located within the zone being served.

3. 9:50 AM - First floor (facility ground floor) Emergency Department suite B, has medical gas zone valves improperly located within the zone being served.

4. 10:00 AM - First floor (facility ground floor) north hallway, medical gas piping lacks required shut-off valves at the base of vertical risers.

Exit interview with maintenance representative #1, and facility administrator on May 8, 2012, between 11:30 AM and 11:45 AM, confirmed the improper location of zone valves and the lack of shut-off valves.