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Based on observation and interview it was determined the facility failed to properly maintain 2-hour fire rated common walls affecting two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 10:31 AM and 1:31 PM, revealed the following deficiencies:

1. 10:31 AM - First floor, common wall above door 1056 is not sealed tight to the deck above, open where corrugated roof meets top of wall.

2. 1:31 PM - Basement level, common wall around door 001 has unprotected penetrations and remaining sheet metal plate does not provide a 2-hour fire resistance rating.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these 2-hour fire rated common wall deficiencies.

Based upon observation and interview, it was determined the facility failed to construct and maintain one common wall in one location on one of three floors.

Findings include:

Observation of the basement-level portion of this component at 11:47 a.m. on July 11, 2012, revealed the absence of a common wall between the boiler building and the above component.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the lack of a common wall at this level.

Based on observation and interview it was determined the facility failed to properly maintain building construction on four of four floors in this component.

Findings include:

A. Observation on July 11, 2012, between 12:40 PM and 1:40 PM, revealed the following deficiencies:

1. 12:40 PM - Fourth floor, typical for all floors below, flooring is comprised of wooden furring strips, wood sub floor and wood finished floor totaling some 2 inches in thickness.

2. 1:00 PM - Fourth floor, typical for all floors below, walls are comprised of individual red bricks and mortar, covered with wooden lath and horse-hair plaster.

3. 1:40 PM - Third floor, typical for all floors below, bathroom has unprotected structural steel within the pipe chase located at door Q314A.

B. Observation on July 12, 2012, at 1:17 PM, revealed unprotected structural steel in the basement level first wet sprinkler riser room.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these building construction deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain building construction on four of four floors within this component.

Findings include:

1. Observation of component building construction between 12:35 p.m. and 2:00 p.m. on July 11, 2012, revealed the below deficiencies:

a. Fourth floor (typical for all floors below) flooring is comprised of wooden furring strips, wooden sub-floor and wood finished floor totaling approximately two inches in thickness. 12:35 p.m. through 12:50 p.m.

b. Fourth floor (typical for all floors below) walls are comprised of individual red bricks and mortar, covered with wooden lath and horse-hair plaster. 1:06 p.m. through 1:22 p.m.

c. Third floor (typical for all floors below) bathrooms possess unprotected structural steel (both columns and floor support steel) within miscellaneous pipe chases. 1:33 p.m. through 1:44 p.m.

d. Observation on July 11, 2012, between 1:50 p.m. and 2:00 p.m. revealed unprotected structural steel at the basement level in miscellaneous locations.

e. Observation of the basement level between 1:50 p.m. and 2:00 p.m. on July 11, 2012, revealed portions of the floor slab assembly removed in several locations.

Exit interview with maintenance representative one, maintenance representative two and design professional one on July 13, 2012 between 11:00 a.m. and 11:30 a.m., confirmed the above building construction deficiencies.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations on three of three total floors.

Findings include:

Observation of various ceiling assemblies within this component between 10:48 a.m. and 11:59 a.m. on July 11, 2012, revealed various ceiling access panels to lack a rating commensurate with the rated ceiling assembly application.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the building construction deficiency stated above.

Based on observation and interview it was determined the facility failed to properly maintain fire rated vertical enclosures affecting four of four floors in this component.

Findings include:

A. Observation on July 11, 2012, between 12:38 PM and 1:37 PM, revealed the following deficiencies:

1. 12:38 PM - Attic level, numerous vertical air shafts spanning four floors, open directly into the attic space.

2. 12:50 PM - Fourth floor, numerous vertical air shafts, spanning four floors, open directly into horizontal brick air ducts that are partially enclosed.

3. 12:52 PM - Fourth floor, vertical pipe chase, accessed by door 4017, had unprotected penetrations, open to two floors below.

4. 1:30 PM - Third floor, electrical closet 3159 had an unprotected vertical penetration around an electrical conduit at the floor level.

5. 1:37 PM - Third floor, vertical pipe chase, accessed by door Q314A, had unprotected penetrations, open to two floors below.

B. Observation on July 12, 2012, between 8:20 AM and 1:20 PM, revealed the following deficiencies:

1. 8:20 AM - Fourth floor, the second exit stair tower had exposed slate risers and tread when viewed from the 3 ? floor landing. This stair-back was not separated from the stair tower by fire rated construction.

2. 1:12 PM - Basement level, two personal clothes dryer, foil ducts that penetrated the basement ceiling from the first floor lack a required fire rated enclosure.

3. 1:20 PM - Sub-tunnel level, these service tunnels, located below the basement level, are not separated from the basement creating numerous unprotected vertical penetrations in the basement floor.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these unprotected vertical penetrations.

Based on observation and interview it was determined the facility failed to properly maintain fire rated vertical enclosures/openings affecting four of four floors in this component.

Findings include:

1. Observation between July 12, 2012, between 08:16 a.m. and 1:30 p.m. revealed the following deficiencies:

a. Numerous vertical air shafts, which span a total of four floors, (in addition to the basement) open directly into the attic spaces. 08:16 a.m. through 08:44 a.m.

b. Numerous vertical air shafts, spanning four floors, open directly into horizontal brick air ducts which are partially enclosed. 08:45 a.m. through 08:49 a.m.

c. The fourth floor portion of the second exit stair tower possesses exposed slate risers which negate the required two-hour fire resistive integrity of the enclosure. 08:55 a.m.

d. Two personal clothes dryers exhaust ducts penetrate the floor slab assembly between basement and first floor levels and lack the requisite enclosure properties. 09:23 a.m.

e. Service tunnels located within this component are not separated from the basement level, thereby creating numerous unprotected vertical penetrations within the basement floor assembly. 10:06 a.m. through 10:37 a.m.

f. A sprinkler riser penetration was noted at the basement level at 12:55 p.m. on July 11, 2012 (located closest to North Block Middle.)

g. Dumb waiter access panels lack rated door frame assemblies at all pertinent levels. 1:06 p.m. through 1:50 p.m. on July 11, 2012.

h. Penetrations of the floor slab assembly were noted within the fourth floor 408 pipe chase at 08:33 a.m. on July 12, 2012.

i. All bath/shower room pipe chases within this component are unenclosed at all pertinent floor slab assemblies.


Exit interview with maintenance representative one, maintenance representative two and design professional one on July 13, 2012, between 11:00 a.m. and 11:30 a.m., confirmed these unprotected vertical penetrations.

Based on observation and interview it was determined the facility failed to properly maintain smoke barrier walls on two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 9:01 AM and 10:56 AM, revealed the following unprotected penetrations in the smoke barrier walls:

1. 9:01 AM - Second floor, unprotected penetration around wires above corridor door 2014.

2. 10:56 AM - First floor, unprotected penetration above corridor door 1039.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these unprotected smoke barrier wall penetrations.`

Based on observation and interview it was determined the facility failed to properly configure hazardous storage areas on three of four floors in this component.

Findings include:

A. Observation on July 11, 2012, between 12:43 PM and 1:22 PM revealed the following hazardous area deficiencies:

1. 12:43 PM - Fourth floor, combustible storage items stored in the corridor.

2. 1:20 PM - Third floor, Room 3039 used to store combustible materials, had an open transom above the door and lacked a self-closing device.

3. 1:22 PM - Third floor, 3000 corridor, combustible wooden beds stored in the corridor.

B. Observation on July 12, 2012, at 11:11 AM revealed the first floor room 1069, soiled linen storage room, a hazardous area lacked a required self-closing device.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these hazardous area deficiencies.

Based upon observation and interview, it was determined the facility failed to properly configure multiple hazardous area enclosures on one of four floors.

Findings include:

Observation of the fourth floor storage rooms (former consumer rooms) between 08:39 a.m. and 08:44 a.m. on July 12, 2012, revealed the room doors to lack self-closing devices.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the hazardous area enclosures to lack required self-closing devices.

Based upon observation and interview, it was determined the facility failed to maintain five exit stair tower locations within this component.

Findings include:

1. Observation of various exit stair towers within this component between 1:16 p.m. on July 11, 2012, and 1:55 p.m. on July 12, 2012, revealed the below deficiencies:

a. The basement-level portion of the North Bank, third section stair tower enclosure lacks one-hour, fire resistive integrity (less one-hour assembly at ceiling level.) 1:16 p.m.
b. Ceiling height within the fourth floor portion of the North Block, first section stair tower enclosure is less than the required height. 08:22 a.m. on July 12, 2012.
c. The fourth floor ceiling of the 343 stair tower is constructed of horse hair plaster and wooden lathe affixed to combustible roof assembly joists. 09:55 a.m. on July 12, 2012.
d. The basement-level portion of the 302 stair tower enclosure is open to the basement level. 1:55 p.m. on July 12, 2012.
e. An unprotected column was noted within the basement-level North Bank, third section stair tower enclosure wall at 1:17 p.m. on July 11, 2012.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the above stair tower enclosure deficiencies.

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

Findings include:

A. Observation on July 11, 2012, at 12:34 PM, revealed the fourth floor exit stair tower landing, located at door 4002, had reduced head room measuring 6 feet 4 inches.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the reduced head room on the fourth floor exit stair tower landing.

Based upon observation and interview, it was determined the facility failed to maintain exit access in one location on one of four floors.

Findings include:

Observation of the fourth floor, third section area at 10:44 a.m. on July 12, 2012, revealed the ceiling height in this area to be reduced to six feet, two inches for a distance of twelve feet, three inches.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the exit access deficiency.

Based on observation and interview it was determined the facility failed to

Findings include:

A. Observation on July 11, 2012, at 1:10 PM, revealed the fourth floor corridor at door 4019 lacked the required continuous lighting.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the fourth floor corridor lacked continuous lighting.

Based on observation and interview it was determined the facility failed to properly configure exit signage on one of four floors in this component.

Findings include:

A. Observation on July 11, 2012, at 1:12 PM, revealed corridor 4019 lacked exit signage on both ends.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the fourth floor corridor lacked visible exit signs.

Based upon observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in multiple locations on one of four floors.

Findings include:

Observation of the fourth floor exit access corridor system between 08:55 a.m. and 09:04 a.m. on July 12, 2012, revealed the absence of illuminated exit signage in numerous locations.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the illuminated exit signage deficiency.

Based on documentation review and interview it was determined the facility failed to properly test installed smoke detectors on one of four floors in this component.

Findings include:

A. Review of smoke detector testing documentation on July 11, 2012 at 8:15 AM revealed the facility did not have documentation available to verify the installed, non-addressable smoke detectors had required sensitivity testing during the past two years.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the facility did not have smoke detector sensitivity testing documentation available.

Based upon documentation review and interview, it was determined the facility failed to properly test installed smoke detection units on one of four floors within this component.

Findings include:

Observation of smoke detection unit testing documentation on July 11, 2012, at 08:15 a.m. revealed the facility to lack documentation to verify the installed, nonassessable smoke detection units had been sensitivity tested within the last two years.

Exit interview with maintenance representative one, maintenance representative two and design professional one between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the facility to lack smoke detection unit sensitivity testing documentation.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system on two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 10:25 AM and 1:23 PM, revealed the following areas lacked required automatic sprinkler coverage:

1. 10:25 AM - First floor vestibule at door 1008A lacked sprinkler coverage.

2. 1:23 PM - Sub-Tunnel system lacks sprinkler coverage.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these areas lacked sprinkler protection.

1. Based upon observation and interview, it was determined the facility failed to provide complete automatic sprinkler protection one of four floors within this component.

Findings include:

Observation of the basement-level sub-tunnel areas between 11:00 a.m. and 11:15 a.m. on July 12, 2012, revealed these areas to lack automatic sprinkler system protection.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:15 a.m. on July 13, 2012, confirmed the sub-tunnel areas to lack automatic sprinkler system protection.

2. Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler systems in one location on one of five floors.

Findings include:

Observation of the basement-level sprinkler system gauges at 12:33 p.m. on July 11, 2012, revealed the gauges in question to be in excess of five years of age.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the sprinkler gauge deficiency.

Based on documentation review and interview it was determined the facility failed to properly test the installed automatic sprinkler system affecting five of five floors in this component.

Findings include:

A. Review of sprinkler testing and inspection documentation on July 11, 2012 at 8:25 AM, revealed the facility did not have documentation available to support conducting a required annual inspection and testing of the installed automatic sprinkler system.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the facility did not have annual sprinkler system inspection and testing documentation available.

Based upon documentation review and interview, it was determined the facility failed to properly test the installed automatic sprinkler system on five of five levels within this component.

Findings include:

Observation of facility automatic sprinkler system testing and inspection documentation between 08:22 a.m. and 08:25 a.m. on July 11, 2012, revealed the facility to lack documentation to support required annual inspection and testing of the sprinkler system.

Exit interview with maintenance representative one, maintenance representative two and design professional one on July 13, 2012, between 11:00 a.m. and 11:30 a.m. confirmed the facility to lack required annual sprinkler system inspection and testing documentation.

Based upon observation and interview, it was determined the facility failed to maintain fire extinguishers in multiple locations on three of three floors.

Findings include:

Observation of flush-mounted fire extinguisher cabinets between 11:33 a.m. and 11:44 a.m. on July 11, 2012, revealed projecting signage lacking in order to aptly identify the fire extinguisher locations.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the fire extinguisher deficiencies.

Based on documentation review, observation and interview it was determined the facility failed to properly configure or inspect the installed heating, cooling and ventilation (HVAC) system affecting four of four floors in this component.

Findings include:

A. Review of fire and smoke damper inspection documentation on July 11, 2012, between 8:35 AM and 8:40 AM, revealed the facility had the following heating, cooling and ventilation (HVAC) system deficiencies:

1. 8:35 AM - Required 4-year inspection of all installed heating, cooling and ventilation duct fire dampers.

2. 8:40 AM - Required 4-year inspection of all installed heating, cooling and ventilation duct smoke dampers.

B. Observation on July 11, between 12:55 PM and 1:00 PM , revealed the following deficiencies:

1. 12:55 PM - Fourth floor HVAC duct located in room 4016 lacked required retaining angles at the floor level.

2. 1:00 PM - Fourth floor HVAC duct located in room 4016 lacked a fire damper access door.

C. Observation on July 12, at 9:06 AM , revealed the second floor corridor HVAC return, located adjacent to the smoke barrier in the first living area, was not completely ducted to the suspended ceiling below.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these heating, cooling and ventilation (HVAC) system deficiencies.

Based upon documentation review and/or observation and interview, it was determined the facility failed to properly install and/or maintain the heating, ventilation and air conditioning systems in multiple locations on four of four floors.

Findings include:

1. Observation of facility heating, ventilation and air conditioning documentation between 08:32 a.m. and 08:38 a.m. on July 11, 2012, and observation of various heating, ventilation and air conditioning systems between 12:40 p.m. on July 11, 2012, and 09:10 a.m. on July 12, 2012, revealed the below deficiencies:

a. The facility lacks documentation to support required four year fire and smoke damper preventive maintenance. 08:32 a.m. through 08:38 a.m. on July 11, 2012.
b. The basement-level common wall with the Administration Building possesses a heat transference duct which lacks a fire damper and retaining angles. 1:10 p.m. on July 11, 2012.
c. Numerous duct penetrations of the floor slab assemblies located within the patient rest room/shower room areas lack retaining angles at their respective floor slab assemblies. 09:33 a.m. through 1:44 p.m. on July 12, 2012.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the heating, ventilation and air conditioning deficiencies stated above.

Based on observation and interview it was determined the facility failed to properly maintain exit corridors on two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 8:50 AM and 10:40 AM, revealed the following deficiencies:

1. 8:50 AM - Second floor, exit corridor in living area had numerous pieces of stationary furniture in the exit corridor.

2. 10:40 AM - First floor, exit corridor in living area had numerous pieces of stationary furniture in the exit corridor.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the stationary furniture in the exit corridors located within the living areas.

Based upon observation and interview, it was determined the facility failed to maintain exit access in multiple locations on one of four floors.

Findings include:

Observation of the fourth floor exit access corridor systems between 09:01 a.m. and 09:14 a.m. on July 12, 2012, revealed numerous storage items located within the corridor systems.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the storage items located within the exit access corridor systems at the fourth floor level.

Based on observation and interview it was determined the facility failed to properly configure liquid oxygen storage and transfer locations on one of four floors in this component.

Findings include:

A. Observation on July 12, 2012,, at 10:46 AM, revealed the second floor room 1020, was not properly configured as a liquid oxygen transfer or storage location, had three 40 liter liquid oxygen dewars along with portable refillable liquid oxygen containers.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed that room 1020 was not properly configured as a liquid oxygen transfer and storage location.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on four of four floors in this component.

Findings include:

A. Observation on July 12, at 1:40 PM, revealed the component did not have a required emergency generator derangement signal located at a 24 hour attended location.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed this component did not have a emergency generator derangement signal located at a 24-hour attended location.

1. Based upon observation and interview, it was determined the facility failed to properly configure the emergency power supply system on four of four floors.

Findings include:

Observation on July 11, 2012, at 11:49 a.m. revealed the facility to lack the required emergency generator set derangement signal located at a twenty-four house manned /staffed location.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the lack of a emergency generator derangement signal located at a twenty-four hour staffed location.

2. Based upon observation and interview, it was determined the facility failed to maintain one generator set location on one of four floors.

Findings include:

Observation of the basement-level generator set room at 12:42 p.m. on July 11, 2012, revealed the enclosure door and door frame assembly to lack a fire resistive label, while the self-closing device has been disabled (Room 0023.)

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the generator set deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one generator set location on one of four floors.

Findings include:

Observation of the basement-level generator set location at 10:55 a.m. on July 11, 2012, revealed the lamp test panel to lack illumination when tested.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the panel to lack illumination.

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

Findings include:

A. Observation on July 12, 2012, between 8:53 AM and 9:00 AM,, revealed the following deficiencies:

1. 8:53 AM - Second floor, sleeping room 2011, bed placed against electrical receptacle.

2. 8:55 AM - Second floor, sleeping room 2145, bed placed against electrical receptacle.

3. 8:57 AM - Second floor, sleeping room 2144, bed placed against electrical receptacle.

4. 9:00 AM - Second floor, sleeping room 2143, bed placed against electrical receptacle.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these electrical distribution system deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain 2-hour fire rated common walls affecting two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 10:31 AM and 1:31 PM, revealed the following deficiencies:

1. 10:31 AM - First floor, common wall above door 1056 is not sealed tight to the deck above, open where corrugated roof meets top of wall.

2. 1:31 PM - Basement level, common wall around door 001 has unprotected penetrations and remaining sheet metal plate does not provide a 2-hour fire resistance rating.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these 2-hour fire rated common wall deficiencies.

Based upon observation and interview, it was determined the facility failed to construct and maintain one common wall in one location on one of three floors.

Findings include:

Observation of the basement-level portion of this component at 11:47 a.m. on July 11, 2012, revealed the absence of a common wall between the boiler building and the above component.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the lack of a common wall at this level.

Based on observation and interview it was determined the facility failed to properly maintain building construction on four of four floors in this component.

Findings include:

A. Observation on July 11, 2012, between 12:40 PM and 1:40 PM, revealed the following deficiencies:

1. 12:40 PM - Fourth floor, typical for all floors below, flooring is comprised of wooden furring strips, wood sub floor and wood finished floor totaling some 2 inches in thickness.

2. 1:00 PM - Fourth floor, typical for all floors below, walls are comprised of individual red bricks and mortar, covered with wooden lath and horse-hair plaster.

3. 1:40 PM - Third floor, typical for all floors below, bathroom has unprotected structural steel within the pipe chase located at door Q314A.

B. Observation on July 12, 2012, at 1:17 PM, revealed unprotected structural steel in the basement level first wet sprinkler riser room.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these building construction deficiencies.

Based on observation and interview it was determined the facility failed to properly maintain building construction on four of four floors within this component.

Findings include:

1. Observation of component building construction between 12:35 p.m. and 2:00 p.m. on July 11, 2012, revealed the below deficiencies:

a. Fourth floor (typical for all floors below) flooring is comprised of wooden furring strips, wooden sub-floor and wood finished floor totaling approximately two inches in thickness. 12:35 p.m. through 12:50 p.m.

b. Fourth floor (typical for all floors below) walls are comprised of individual red bricks and mortar, covered with wooden lath and horse-hair plaster. 1:06 p.m. through 1:22 p.m.

c. Third floor (typical for all floors below) bathrooms possess unprotected structural steel (both columns and floor support steel) within miscellaneous pipe chases. 1:33 p.m. through 1:44 p.m.

d. Observation on July 11, 2012, between 1:50 p.m. and 2:00 p.m. revealed unprotected structural steel at the basement level in miscellaneous locations.

e. Observation of the basement level between 1:50 p.m. and 2:00 p.m. on July 11, 2012, revealed portions of the floor slab assembly removed in several locations.

Exit interview with maintenance representative one, maintenance representative two and design professional one on July 13, 2012 between 11:00 a.m. and 11:30 a.m., confirmed the above building construction deficiencies.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations on three of three total floors.

Findings include:

Observation of various ceiling assemblies within this component between 10:48 a.m. and 11:59 a.m. on July 11, 2012, revealed various ceiling access panels to lack a rating commensurate with the rated ceiling assembly application.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the building construction deficiency stated above.

Based on observation and interview it was determined the facility failed to properly maintain fire rated vertical enclosures affecting four of four floors in this component.

Findings include:

A. Observation on July 11, 2012, between 12:38 PM and 1:37 PM, revealed the following deficiencies:

1. 12:38 PM - Attic level, numerous vertical air shafts spanning four floors, open directly into the attic space.

2. 12:50 PM - Fourth floor, numerous vertical air shafts, spanning four floors, open directly into horizontal brick air ducts that are partially enclosed.

3. 12:52 PM - Fourth floor, vertical pipe chase, accessed by door 4017, had unprotected penetrations, open to two floors below.

4. 1:30 PM - Third floor, electrical closet 3159 had an unprotected vertical penetration around an electrical conduit at the floor level.

5. 1:37 PM - Third floor, vertical pipe chase, accessed by door Q314A, had unprotected penetrations, open to two floors below.

B. Observation on July 12, 2012, between 8:20 AM and 1:20 PM, revealed the following deficiencies:

1. 8:20 AM - Fourth floor, the second exit stair tower had exposed slate risers and tread when viewed from the 3 ? floor landing. This stair-back was not separated from the stair tower by fire rated construction.

2. 1:12 PM - Basement level, two personal clothes dryer, foil ducts that penetrated the basement ceiling from the first floor lack a required fire rated enclosure.

3. 1:20 PM - Sub-tunnel level, these service tunnels, located below the basement level, are not separated from the basement creating numerous unprotected vertical penetrations in the basement floor.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these unprotected vertical penetrations.

Based on observation and interview it was determined the facility failed to properly maintain fire rated vertical enclosures/openings affecting four of four floors in this component.

Findings include:

1. Observation between July 12, 2012, between 08:16 a.m. and 1:30 p.m. revealed the following deficiencies:

a. Numerous vertical air shafts, which span a total of four floors, (in addition to the basement) open directly into the attic spaces. 08:16 a.m. through 08:44 a.m.

b. Numerous vertical air shafts, spanning four floors, open directly into horizontal brick air ducts which are partially enclosed. 08:45 a.m. through 08:49 a.m.

c. The fourth floor portion of the second exit stair tower possesses exposed slate risers which negate the required two-hour fire resistive integrity of the enclosure. 08:55 a.m.

d. Two personal clothes dryers exhaust ducts penetrate the floor slab assembly between basement and first floor levels and lack the requisite enclosure properties. 09:23 a.m.

e. Service tunnels located within this component are not separated from the basement level, thereby creating numerous unprotected vertical penetrations within the basement floor assembly. 10:06 a.m. through 10:37 a.m.

f. A sprinkler riser penetration was noted at the basement level at 12:55 p.m. on July 11, 2012 (located closest to North Block Middle.)

g. Dumb waiter access panels lack rated door frame assemblies at all pertinent levels. 1:06 p.m. through 1:50 p.m. on July 11, 2012.

h. Penetrations of the floor slab assembly were noted within the fourth floor 408 pipe chase at 08:33 a.m. on July 12, 2012.

i. All bath/shower room pipe chases within this component are unenclosed at all pertinent floor slab assemblies.


Exit interview with maintenance representative one, maintenance representative two and design professional one on July 13, 2012, between 11:00 a.m. and 11:30 a.m., confirmed these unprotected vertical penetrations.

Based on observation and interview it was determined the facility failed to properly maintain smoke barrier walls on two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 9:01 AM and 10:56 AM, revealed the following unprotected penetrations in the smoke barrier walls:

1. 9:01 AM - Second floor, unprotected penetration around wires above corridor door 2014.

2. 10:56 AM - First floor, unprotected penetration above corridor door 1039.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these unprotected smoke barrier wall penetrations.`

Based on observation and interview it was determined the facility failed to properly configure hazardous storage areas on three of four floors in this component.

Findings include:

A. Observation on July 11, 2012, between 12:43 PM and 1:22 PM revealed the following hazardous area deficiencies:

1. 12:43 PM - Fourth floor, combustible storage items stored in the corridor.

2. 1:20 PM - Third floor, Room 3039 used to store combustible materials, had an open transom above the door and lacked a self-closing device.

3. 1:22 PM - Third floor, 3000 corridor, combustible wooden beds stored in the corridor.

B. Observation on July 12, 2012, at 11:11 AM revealed the first floor room 1069, soiled linen storage room, a hazardous area lacked a required self-closing device.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these hazardous area deficiencies.

Based upon observation and interview, it was determined the facility failed to properly configure multiple hazardous area enclosures on one of four floors.

Findings include:

Observation of the fourth floor storage rooms (former consumer rooms) between 08:39 a.m. and 08:44 a.m. on July 12, 2012, revealed the room doors to lack self-closing devices.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the hazardous area enclosures to lack required self-closing devices.

Based upon observation and interview, it was determined the facility failed to maintain five exit stair tower locations within this component.

Findings include:

1. Observation of various exit stair towers within this component between 1:16 p.m. on July 11, 2012, and 1:55 p.m. on July 12, 2012, revealed the below deficiencies:

a. The basement-level portion of the North Bank, third section stair tower enclosure lacks one-hour, fire resistive integrity (less one-hour assembly at ceiling level.) 1:16 p.m.
b. Ceiling height within the fourth floor portion of the North Block, first section stair tower enclosure is less than the required height. 08:22 a.m. on July 12, 2012.
c. The fourth floor ceiling of the 343 stair tower is constructed of horse hair plaster and wooden lathe affixed to combustible roof assembly joists. 09:55 a.m. on July 12, 2012.
d. The basement-level portion of the 302 stair tower enclosure is open to the basement level. 1:55 p.m. on July 12, 2012.
e. An unprotected column was noted within the basement-level North Bank, third section stair tower enclosure wall at 1:17 p.m. on July 11, 2012.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the above stair tower enclosure deficiencies.

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

Findings include:

A. Observation on July 11, 2012, at 12:34 PM, revealed the fourth floor exit stair tower landing, located at door 4002, had reduced head room measuring 6 feet 4 inches.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the reduced head room on the fourth floor exit stair tower landing.

Based upon observation and interview, it was determined the facility failed to maintain exit access in one location on one of four floors.

Findings include:

Observation of the fourth floor, third section area at 10:44 a.m. on July 12, 2012, revealed the ceiling height in this area to be reduced to six feet, two inches for a distance of twelve feet, three inches.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the exit access deficiency.

Based on observation and interview it was determined the facility failed to

Findings include:

A. Observation on July 11, 2012, at 1:10 PM, revealed the fourth floor corridor at door 4019 lacked the required continuous lighting.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the fourth floor corridor lacked continuous lighting.

Based on observation and interview it was determined the facility failed to properly configure exit signage on one of four floors in this component.

Findings include:

A. Observation on July 11, 2012, at 1:12 PM, revealed corridor 4019 lacked exit signage on both ends.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the fourth floor corridor lacked visible exit signs.

Based upon observation and interview, it was determined the facility failed to install and maintain illuminated exit signage in multiple locations on one of four floors.

Findings include:

Observation of the fourth floor exit access corridor system between 08:55 a.m. and 09:04 a.m. on July 12, 2012, revealed the absence of illuminated exit signage in numerous locations.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the illuminated exit signage deficiency.

Based on documentation review and interview it was determined the facility failed to properly test installed smoke detectors on one of four floors in this component.

Findings include:

A. Review of smoke detector testing documentation on July 11, 2012 at 8:15 AM revealed the facility did not have documentation available to verify the installed, non-addressable smoke detectors had required sensitivity testing during the past two years.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the facility did not have smoke detector sensitivity testing documentation available.

Based upon documentation review and interview, it was determined the facility failed to properly test installed smoke detection units on one of four floors within this component.

Findings include:

Observation of smoke detection unit testing documentation on July 11, 2012, at 08:15 a.m. revealed the facility to lack documentation to verify the installed, nonassessable smoke detection units had been sensitivity tested within the last two years.

Exit interview with maintenance representative one, maintenance representative two and design professional one between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the facility to lack smoke detection unit sensitivity testing documentation.

Based on observation and interview it was determined the facility failed to provide a complete automatic sprinkler system on two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 10:25 AM and 1:23 PM, revealed the following areas lacked required automatic sprinkler coverage:

1. 10:25 AM - First floor vestibule at door 1008A lacked sprinkler coverage.

2. 1:23 PM - Sub-Tunnel system lacks sprinkler coverage.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these areas lacked sprinkler protection.

1. Based upon observation and interview, it was determined the facility failed to provide complete automatic sprinkler protection one of four floors within this component.

Findings include:

Observation of the basement-level sub-tunnel areas between 11:00 a.m. and 11:15 a.m. on July 12, 2012, revealed these areas to lack automatic sprinkler system protection.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:15 a.m. on July 13, 2012, confirmed the sub-tunnel areas to lack automatic sprinkler system protection.

2. Based upon observation and interview, it was determined the facility failed to maintain the automatic sprinkler systems in one location on one of five floors.

Findings include:

Observation of the basement-level sprinkler system gauges at 12:33 p.m. on July 11, 2012, revealed the gauges in question to be in excess of five years of age.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the sprinkler gauge deficiency.

Based on documentation review and interview it was determined the facility failed to properly test the installed automatic sprinkler system affecting five of five floors in this component.

Findings include:

A. Review of sprinkler testing and inspection documentation on July 11, 2012 at 8:25 AM, revealed the facility did not have documentation available to support conducting a required annual inspection and testing of the installed automatic sprinkler system.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the facility did not have annual sprinkler system inspection and testing documentation available.

Based upon documentation review and interview, it was determined the facility failed to properly test the installed automatic sprinkler system on five of five levels within this component.

Findings include:

Observation of facility automatic sprinkler system testing and inspection documentation between 08:22 a.m. and 08:25 a.m. on July 11, 2012, revealed the facility to lack documentation to support required annual inspection and testing of the sprinkler system.

Exit interview with maintenance representative one, maintenance representative two and design professional one on July 13, 2012, between 11:00 a.m. and 11:30 a.m. confirmed the facility to lack required annual sprinkler system inspection and testing documentation.

Based upon observation and interview, it was determined the facility failed to maintain fire extinguishers in multiple locations on three of three floors.

Findings include:

Observation of flush-mounted fire extinguisher cabinets between 11:33 a.m. and 11:44 a.m. on July 11, 2012, revealed projecting signage lacking in order to aptly identify the fire extinguisher locations.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the fire extinguisher deficiencies.

Based on documentation review, observation and interview it was determined the facility failed to properly configure or inspect the installed heating, cooling and ventilation (HVAC) system affecting four of four floors in this component.

Findings include:

A. Review of fire and smoke damper inspection documentation on July 11, 2012, between 8:35 AM and 8:40 AM, revealed the facility had the following heating, cooling and ventilation (HVAC) system deficiencies:

1. 8:35 AM - Required 4-year inspection of all installed heating, cooling and ventilation duct fire dampers.

2. 8:40 AM - Required 4-year inspection of all installed heating, cooling and ventilation duct smoke dampers.

B. Observation on July 11, between 12:55 PM and 1:00 PM , revealed the following deficiencies:

1. 12:55 PM - Fourth floor HVAC duct located in room 4016 lacked required retaining angles at the floor level.

2. 1:00 PM - Fourth floor HVAC duct located in room 4016 lacked a fire damper access door.

C. Observation on July 12, at 9:06 AM , revealed the second floor corridor HVAC return, located adjacent to the smoke barrier in the first living area, was not completely ducted to the suspended ceiling below.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these heating, cooling and ventilation (HVAC) system deficiencies.

Based upon documentation review and/or observation and interview, it was determined the facility failed to properly install and/or maintain the heating, ventilation and air conditioning systems in multiple locations on four of four floors.

Findings include:

1. Observation of facility heating, ventilation and air conditioning documentation between 08:32 a.m. and 08:38 a.m. on July 11, 2012, and observation of various heating, ventilation and air conditioning systems between 12:40 p.m. on July 11, 2012, and 09:10 a.m. on July 12, 2012, revealed the below deficiencies:

a. The facility lacks documentation to support required four year fire and smoke damper preventive maintenance. 08:32 a.m. through 08:38 a.m. on July 11, 2012.
b. The basement-level common wall with the Administration Building possesses a heat transference duct which lacks a fire damper and retaining angles. 1:10 p.m. on July 11, 2012.
c. Numerous duct penetrations of the floor slab assemblies located within the patient rest room/shower room areas lack retaining angles at their respective floor slab assemblies. 09:33 a.m. through 1:44 p.m. on July 12, 2012.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the heating, ventilation and air conditioning deficiencies stated above.

Based on observation and interview it was determined the facility failed to properly maintain exit corridors on two of four floors in this component.

Findings include:

A. Observation on July 12, 2012, between 8:50 AM and 10:40 AM, revealed the following deficiencies:

1. 8:50 AM - Second floor, exit corridor in living area had numerous pieces of stationary furniture in the exit corridor.

2. 10:40 AM - First floor, exit corridor in living area had numerous pieces of stationary furniture in the exit corridor.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed the stationary furniture in the exit corridors located within the living areas.

Based upon observation and interview, it was determined the facility failed to maintain exit access in multiple locations on one of four floors.

Findings include:

Observation of the fourth floor exit access corridor systems between 09:01 a.m. and 09:14 a.m. on July 12, 2012, revealed numerous storage items located within the corridor systems.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the storage items located within the exit access corridor systems at the fourth floor level.

Based on observation and interview it was determined the facility failed to properly configure liquid oxygen storage and transfer locations on one of four floors in this component.

Findings include:

A. Observation on July 12, 2012,, at 10:46 AM, revealed the second floor room 1020, was not properly configured as a liquid oxygen transfer or storage location, had three 40 liter liquid oxygen dewars along with portable refillable liquid oxygen containers.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed that room 1020 was not properly configured as a liquid oxygen transfer and storage location.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on four of four floors in this component.

Findings include:

A. Observation on July 12, at 1:40 PM, revealed the component did not have a required emergency generator derangement signal located at a 24 hour attended location.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed this component did not have a emergency generator derangement signal located at a 24-hour attended location.

1. Based upon observation and interview, it was determined the facility failed to properly configure the emergency power supply system on four of four floors.

Findings include:

Observation on July 11, 2012, at 11:49 a.m. revealed the facility to lack the required emergency generator set derangement signal located at a twenty-four house manned /staffed location.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the lack of a emergency generator derangement signal located at a twenty-four hour staffed location.

2. Based upon observation and interview, it was determined the facility failed to maintain one generator set location on one of four floors.

Findings include:

Observation of the basement-level generator set room at 12:42 p.m. on July 11, 2012, revealed the enclosure door and door frame assembly to lack a fire resistive label, while the self-closing device has been disabled (Room 0023.)

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the generator set deficiency.

Based upon observation and interview, it was determined the facility failed to maintain one generator set location on one of four floors.

Findings include:

Observation of the basement-level generator set location at 10:55 a.m. on July 11, 2012, revealed the lamp test panel to lack illumination when tested.

Exit interview with maintenance representative one, maintenance representative two and design professional one during the exit interview process conducted between 11:00 a.m. and 11:30 a.m. on July 13, 2012, confirmed the panel to lack illumination.

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

Findings include:

A. Observation on July 12, 2012, between 8:53 AM and 9:00 AM,, revealed the following deficiencies:

1. 8:53 AM - Second floor, sleeping room 2011, bed placed against electrical receptacle.

2. 8:55 AM - Second floor, sleeping room 2145, bed placed against electrical receptacle.

3. 8:57 AM - Second floor, sleeping room 2144, bed placed against electrical receptacle.

4. 9:00 AM - Second floor, sleeping room 2143, bed placed against electrical receptacle.

Exit interview with maintenance representative #1, maintenance representative #2, and design professional #1 on July 13, 2012 between 11:00 AM and 11:30 AM, confirmed these electrical distribution system deficiencies.