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Based on observation and interview, it was determined the facility failed to properly maintain one two-hour fire rated common wall affecting one of six smoke compartments in this component.

Findings include:

Observation on April 9, 2012, at 12:30 PM, revealed the right leaf of the double set of doors serving the two-hour fire rated common wall adjacent to the first floor dietary department did not fully self-close when tested.

Exit interview with facility representative #1, on April 9, 2012, between 1:15 PM and 1:30 PM, confirmed the door sweep had prevented this two-hour fire rated door from fully closing in its frame.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in six of six smoke compartments in this component.

Findings include:

Observation of building construction on April 9, 2012, between 9:30 AM and 1:15 PM, revealed the facility exceeds maximum allowable story height for this type of construction.

Exit interview with facility representative #1, on April 9, 2012, between 1:15 PM and 1:30 PM, confirmed the facility exceeds maximum allowable story height for this type of construction and identified the facility has an acceptable Fire Safety Evaluation System (FSES), revised on April 9, 2012, addressing this issue.

Based on observation and interview, it was determined the facility failed to properly maintain exit corridor walls in one of thirteen smoke compartments in this component.

Findings include:

Observation on April 9, 2012 at 2:20 PM, revealed a penetration around electrical wires in the corridor wall above the suspended ceiling outside the 5-North medication room.

Exit Interview with facility representative #1, on April 9, 2012, between 3:15 PM and 3:30 PM confirmed the penetration in this unsprinklered exit corridor wall.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures affecting one of ten smoke compartments within this component.

Findings include:

Observation of vertical enclosures on April 10, 2012, between 8:00 AM and 11:45 AM revealed the elevator vertical enclosure had less than the required fire resistance rating.

Exit interview with facility representative #1, on April 10, 2012, between 11:45 AM and 12:00 PM, confirmed the structural steel integral to the elevator shaft construction lacked the required fire resistance rating and identified the facility has an acceptable Fire Safety Evaluation System (FSES), reviewed on April 10, 2012, addressing this issue

Based on observation and interview, it was determined the facility failed to provide two acceptable exits from the basement level affecting one of six smoke compartments in this component.

Findings include:

Observation on April 9, 2012, at 1:05 PM, revealed the basement level lacked a second acceptable exit.

Exit interview with facility representative #1, on April 9, 2012, between 1:15 PM and 1:30 PM, confirmed the basement level lacked the required second exit and identified the facility has an acceptable Fire Safety Evaluation System (FSES), revised on April 9, 2012, addressing this issue

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

Findings include:

Observation on April 9, 2012, at 12:35 PM, revealed a cart stored on the first floor landing of the Administrative exit stair tower.

Exit interview with facility representative #1, on April 9, 2012, between 1:15 PM and 1:30 PM, confirmed the cart was stored in the exit stair tower enclosure.

Based on observation and interview, it was determined the facility failed to properly store medical gas cylinders in one of ten smoke compartments in this component.

Findings include:

A. Observation on April 10, 2012, between 9:40 AM and 9:48 AM, revealed the following medical gas cylinder storage deficiencies:

1. 9:40 AM - Third floor ICU room 312 was being used to store 23 E-sized oxygen cylinders and 1 H-sized oxygen cylinder. The room was not properly configured as a medical gas cylinder storage area.

2. 9:48 AM - Third floor ICU room 315, 1 E-sized oxygen cylinder was sitting on the floor unsecured.

Exit interview with facility representative #1, on April 10, 2012, between 11:45 AM and 12:00 PM, confirmed these medical gas cylinder storage deficiencies.