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Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of six floors.

Findings include:

1. Observation on November 4, 019, at 10:37 a.m., revealed a conduit and data wire penetration of the first floor common wall with the administration building.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the common wall deficiency.

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

Findings include:

1. Observation between 10:12 a.m., on November 4, 2019, and 9:15 a.m., on November 5, 2019, revealed the following:

a. 9:15 a.m., on November 4, vertical penetrations of the floor slab assembly within the first floor cafeteria.
b. 11:50 a.m., on November 4, vertical penetrations of the floor /roof assembly within patient room 302.
c. 9:12 a.m., on November 5, non-rated foam insulating materials sealed the floor slab assembly within the basement-level mechanical room 5.
d. 9:15 a.m., on November 5, unprotected structural steel within the exit access corridor system closest to the basement-level west stair tower entrance.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the building construction deficiencies.

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

Findings include:

1. Observation on November 4, 2019, between 10:28 a.m. and 10:33 a.m., revealed the following:

a. 10:28 a.m., a cart was located within the first floor portion of the west/main stair tower.
b. 10:33 a.m., the first floor, west/main stair tower lobby entrance doors (protected passageway) required adjustment to fully latch.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the stair tower enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in two locations, affecting two of six floors.

Findings include:

1. Observation between 10:00 a.m., on November 4, 2019, and 8:20 a.m., on November 5, 2019, revealed the following areas required additional illuminated exit signage:

a. 10:00 a.m., on November 4, first floor, MAB stair tower enclosure (one story down to exit discharge).
b. 8:20 a.m., on November 5, 2019, SPU (on west side of suite).

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the emergency lighting deficiencies.

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

Findings include:

1. Observation on November 4, 2019, between 10:22 a.m. and 11:11 a.m., revealed the following:

a. 10:22 a.m., a penetration within the former dumb waiter shaft at the first floor level.
b. 10:44 a.m., unsprayed structural steel within the shaft enclosure located closest to the first floor, C elevator.
b. 11:11 a.m., unsealed penetrations in the right, rear corner of the shaft enclosure located closest to first floor elevator C.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the vertical openings deficiencies.

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures in three locations, affecting one of six floors.

Findings include:

1. Observation on November 5, 2019, between 8:44 a.m. and 8:50 a.m., revealed the following:

a. 8:44 a.m., the second floor OR Equipment Room door lacked smoke-tight integrity.
b. 8:50 a.m., the second floor PACU Soiled Utility Room doors (2) lacked self-closing devices.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the hazardous area enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one location, affecting one of six floors.

Findings include:

1. Observation on November 4, 2019, at 11:04 a.m., revealed multiple penetrations of the suspended ceiling assembly within the first floor, C Elevator exit access corridor system.

Exit interview with the Facilities Manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the corridor wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of six floors.

Findings include:

1. Observation on November 4, 2019, between 10:16 a.m. and 11:48 a.m., revealed the following:

a. 10:16 a.m., the first floor cafeteria door did not fully latch.
b. 11:48 a.m., the third floor, Patient Room 302, door lacked smoke-tight integrity.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one opening within a corridor.

Findings include:

1. Observation on November 5, 2019, at 9:33 a.m., revealed a transfer grill (open to Mechanical Room 5) was located within the basement-level exit access corridor system.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the opening within the corridor deficiency.

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting one of six floors.

Findings include:

1. Observation on November 5, 2019, at 8:32 a.m., revealed several penetrations of the portion of the Elevator A Lobby smoke barrier separation, located above the smoke barrier doors.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the smoke barrier separation wall deficiency.

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

Findings include:

1. Observation on November 4, 2019, at 11:33 a.m., revealed the duct flange, located within the third floor Med-Surg Unit pantry, protruded from the shaft enclosure wall.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the heating, ventilation, and air conditioning deficiency.

Based on observation and interview, it was determined the facility failed to maintain medical gas piping in one location, affecting one of six floors.

Findings include:

1. Observation on November 4, 2019, at 11:52 a.m., revealed oxygen and vacuum piping, located within third floor Patient Room 302, lacked proper labeling with respect to color.

Exit interview with the facilities manager on November 5, 2019, between 10:45 a.m. and 11:00 a.m., confirmed the medical gas piping deficiency.