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Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of four floors.

Findings include:

1. Observation on April 26, 2017, at 9:33 a.m. revealed combustible construction plastic was located above the suspended ceiling assembly within the second floor Orthopaedic Waiting Room.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the construction deficiency.

Based on observation and interview, it was determined the facility failed to maintain three stair towers, affecting three of four floors.

Findings include:

1. Observation on April 26, 2017, between 7:59 a.m. and 12:47 p.m. revealed the following:

a. 7:59 a.m., items were located within the third floor portion of stair tower SC.
b. 10:22 a.m., the second floor portion of the stair tower SA door frame assembly lacked a label denoting fire resistive rating.
c. 12:47 p.m., the Bio-Med suite separation/stair tower vestibule door and door frame assembly lacked labeling denoting fire resistive integrity. In addition, the vision panel glass was non-rated.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the exit stair tower deficiencies.

Based on observation and interview, it was determined the facility failed to maintain vertical opening in one location, affecting one of four floors.

Findings include:

1. Observation on April 26, 2017, at 8:16 a.m. revealed a BX penetration of the third floor portion of the fright elevator enclosure.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the vertical opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain one alcohol-based hand rub stations, affecting one of two floors.

Findings include:

1. Observation on April 27, 2017, at 8:02 a.m. revealed the alcohol-based hand rub station, located closest to the common wall, was positioned over a trash receptacle.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the alcohol-based hand rub deficiency.

Based on observation and interview, it was determined the facility failed to maintain two alcohol-based hand rub stations, affecting one of four floors.

Findings include:

1. Observation on April 26, 2017, between 8:25 a.m. and 12:50 p.m. revealed the following:

a. 8:25 a.m., an alcohol-based hand rub station was positioned over a trash receptacle within Room 3417.
b. 12:50 p.m., an alcohol-based hand rub station was positioned over a trash receptacle at the first floor "sneeze station".

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the alcohol-based hand rub deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors.

Findings include:

1. Observation on April 26, 2017, at 8:13 a.m. revealed storage items were located within eighteen inches of an adjacent sprinkler head assembly within the PT/OT Office closet.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the automatic sprinkler system deficiency.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishing devices in one location, affecting one of four floors.

Findings include:

1. Observation on April 26, 2017, at 7:55 a.m. revealed the portable fire extinguisher within the penthouse resided on the floor.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the portable fire extinguisher deficiency.

Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting three of four floors.

Findings include:

1. Observation on April 26, 2017, between 8:33 a.m. and 10:24 a.m., and April 27, 2017, at 9:40 a.m. revealed the following:

a. 8:33 a.m. on April 26, 2017, the Room 3417 corridor door required adjustment to fully latch within the corresponding door frame assembly.
b. 10:24 a.m. on April 26, 2017, the second floor Clean Supply Room (2133) door required adjustment.
c. 9:40 a.m. on April 27, 2017, the first floor, M1371 corridor door required adjustment to fully latch within the corresponding door frame assembly.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation walls, affecting two of four floors.

Findings include:

1. Observation on April 26, 2017, at 10:40 a.m. and on April 27, 2017, at 9:01 a.m. revealed the following:

a. April 26, 2017, 10:40 a.m., penetrations were noted above the smoke barrier separation doors closest to 2325.
b. April 27, 2017, at 9:01 a.m., penetrations of the smoke barrier separation wall were noted closest to room 1467, within the exit access corridor system.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the smoke barrier separation wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of four floors.

Findings include:

1. Observation on April 26, 2017, at 9:22 a.m. revealed construction lighting was located within the third floor, North Wing penthouse.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the electrical systems deficiency.

Based on observation and interview, it was determined the facility failed to maintain the medical gas system in two locations, affecting two of four floors.

Findings include:

1. Observation on April 26, 2017, between 8:40 a.m. and 10:30 a.m., revealed the following:

a. 8:40 a.m., zone valve boxes within third floor Pediatrics lacked proper labeling.
b. 10:30 a.m., BX wires were touching medical gas piping within the second floor D 2141.

Exit interview with Director of Facilities and Facilities Manager, between 10:15 a.m. and 10:30 a.m. on April 27, 2017, confirmed the medical gas system deficiencies.