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Based on observation and interview it was determined the facility failed to maintain building construction components in multiple instances affecting three of four floors within this component.

Findings include:

1. Observation on November 9, 2016, between 9:09 a.m. and 1:22 p.m. revealed the following:

a. 9:09 a.m., ramp steel within the basement level lacked spray fireproofing.
b. 9:12 a.m., a penetration of the basement level Medical Records rated ceiling assembly.
c. 10:16-10:30 a.m., numerous penetrations of the metal lathe and plaster portion of the basement-level rated ceiling assembly were noted within the "Catch All Storage Room.
d. 10:49 a.m., a penetration of the rated ceiling assembly was noted within the basement level Elevator Lobby.
e. 1:12 p.m., an unprotected structural steel column was noted within the first floor Family Practice.
f. 1:17 p.m., an unprotected structural steel lentil was noted within the first floor Mailroom.
g. 1:22 p.m., all exterior-located structural steel, which supports the ambulance ramp and subsequent floors, lacked spray fireproofing.
h. 11:33 a.m., the canvas awning over the third floor (facility second floor) outdoor smokers' patio lacked labeling indicating the canvas was fire resistive in nature.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed these construction deficiencies.

Based on observation and interview, it was determimed the facility failed to install and maintain exit lighting in multiple locations on two of five levels.

Findings include:

1. Observation on November 09, 2016, between 8:42 a.m. and 11:03 a.m. revealed the following:

a. 8:42 a.m., the exit sign within the attic spaces lacked illumination.
b. 8:43 a.m.-8:50 a.m., multiple areas within the attic spaces lacked illuminated, directional exit signage.
c. 11:03 a.m., illiminated exit signage was lacking within the north west corridor of the Type 50 Suite.

Exit interview with facility maintenance representatives one, two and three on November 09, 2016, between 1:25 p.m. and 1:30 p.m. confirmed the exit and directional signage deficiencies.

Based on observation and interview, it was determined the facility failed to maintain vertical openings in four locations, affecting four of five levels.

Findings include:

1. Observation on November 09, 2016, between 8:40 a.m. and 1:25 p.m. revealed the following:

a. 8:40 a.m., unprotected steel was noted within the attic-level portion of the west elevator shaft enclosure.
b. 8:46 a.m., unprotected steel was noted within the attic-level portion of the east elevator shaft enclosure.
c. 9:12 a.m., the basement-level pipe shaft enclosure, located closest to the north stair tower, lacked a rated, door, door frame, fire-rated door hardware, and self-closing device.
d. 9:22 a.m., the basement-level pipe shaft enclosure lacked a self-closing device and the recessed, wall electrical panel also compromised required integrity.
e. 9:26 a.m., a cable television box and associated cables were installed within the attic-level portion of the "C" stair tower enclosure.
f. 10:33 a.m., Fourth floor (facility third), visitor/staff elevator shaft enclosure had penetration, when viewed to left from inside the car.
g. 1:25 p.m., Second floor (facility first), unprotected penetration in corridor wall into the SE exit stair tower near the expansion joint.

Exit interview with facility maintenance representatives one, two and three on November 09, 2016, between 1:25 p.m. and 1:30 p.m. confirmed the vertical opening deficiencies.

Based on observation and interview it was determined the facility failed to maintain hazardous areas affecting two of four floors in this component.

Findings include:

1. Observation on November 9, 2016, between 9:33 a.m. and 1:01 p.m., revealed the following hazardous area deficiencies:

a. 9:33 a.m. - First floor (facility basement), main storage room , corridor door had a louvered panel.
b. 9:34 a.m. - First floor (facility basement), medical records storage room #2, corridor door had a louvered panel.
c. 9:35 a.m. - First floor (facility basement), medical records storage room #2, door lacked a self-closing device.
d. 10:12 a.m. - First floor (facility basement), Environmental services storage and charging area lacked required enclosure. Area was open to the corridor.
e. 10:50 a.m. - First floor (facility basement), Type 50 storage room door lacked a required self-closing device.
f. 1:00 p.m. - Second floor (facility first), large medical records storage room door did not fully close and latch in its frame when tested.
g. 1:01 p.m. - Second floor (facility first), large medical records storage room door lacked a required self-closing device.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed these hazardous area deficiencies.

Based on observation and interview it was determined the facility failed to provide complete automatic sprinkler protection affecting four of five levels within this component.

Findings include:

1. Observation on November 9, 2016, between 10:15 a.m. and 12:55 p.m., revealed the following sprinkler system deficiencies:

a. 10:15 a.m. - Fourth floor (facility third), NE exit stair tower top landing, outside Adult Unit 1, lacked sprinkler protection.
b. 10:42 a.m. - First floor (facility basement), communications closet near the catch-all storage, lacked sprinkler protection.
c. 10:55 a.m., The basement-level, Communications Closet lacked sprinkler protection.
d. 11:01 a.m. - First floor (facility basement), the Type 50 condensate return pump room, lacked sprinkler protection.
e. 11:30 a.m., The basement-level, Condensate Return Room lacked sprinkler protection.
f. 12:40 p.m. - First floor (facility basement), parking area located under Welter Lane, located within the building envelope, lacked sprinkler protection.
g. 12:55 p.m. - Second floor (facility first), the Welter Lane ambulance access road and parking area, located within the building envelope, lacked sprinkler protection.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed these sprinkler system deficiencies.

Based on observation and interview it was determined the facility failed to maintain installed sprinkler system components affecting three of four floors within this component.

Findings include:

1. Observation on November 9, 2016, between 9:19 a.m. and 1:09 a.m. revealed the following:

a. 9:19 a.m., ceiling tiles were lacking within the basement-level, Medical Records Room.
b. 10:39 a.m., ceiling tiles were lacking within the basement-level, Catch-All Storage Room.
c. 1:09 p.m., ceiling tiles were lacking within the basement-level, Sprinkler Room II.
d. 11:00 a.m., numerous communications wires were lying atop sprinkler distribution piping in the fourth floor (facility third) Adult Unit 3 Utilization and Review conference room.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed the sprinkler system components deficiencies.

Based on observation and interview it was determined the facility failed to maintain one of over thirty five corridor doors in this component.

Findings include:

1. Observation on November 9, 2016, between 11:40 a.m. and 11:42 a.m., revealed the third floor (facility second) nurses station #5 had a dutch door that had the following deficiencies:

a. 11:40 a.m. - Corridor door was a dutch door that did not have the required rabbet, bevel or astragal between the upper and lower half.
b. 11:42 a.m. - Upper half of dutch door had a manual throw bolt to latch the door to the lower half. The upper half did not have independent latching in its frame.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed these corridor door deficiencies.

Based on observation and interview it was determined the facility failed to maintain the installed electrical system in one instance affecting one of four floors in this component.

Findings include:

1. Observation on November 9, 2016, at 10:20 a.m., revealed a surge suppressor power strip was used to power a refrigerator in the Adult Unit 1 employee breakroom.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed the refrigerator was powered by an unauthorized surge suppressor power strip.

Based on observation and interview, it was determined the facility failed to install and maintain the heating, ventilation, and air conditioning system in one location, affecting one of five floors.

Findings include:

1. Observation on November 09, 2016, at 10:16 a.m. revealed the basement-level exhaust duct, located within the shaft wall assembly, lacked a fire damper and retaining angles.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed the heating, ventilation and air conditioning deficiency.

Based on observation and interview it was determined the facility failed to maintain designated smoking area in one instance in this component.

Findings include:

1. Observation on November 9, 2016, at 11:35 a.m., revealed discarded cigarette butts mixed with combustible trash, in a trash can on the third floor (facility second floor) outdoor smokers' patio.

Exit interview with facility maintenance representatives #1, #2 and #3 on November 9, 2016, between 1:25 p.m. and 1:30 p.m., confirmed that cigarette butts had been improperly disposed in a trash can.