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Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of nine floors.

Findings include:

1. Observation made on January 10, 2018, at 12:52 pm, revealed the 1st floor Cathcart Building had unsealed penetrations above the fire doors near the cafeteria on both sides.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed penetrations of the common wall.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of structural components, affecting one of three levels.

Findings Include:

1. Observation on January 10, 2018 at 9:15 am, revealed on the entire second floor of the facility, the structural steel lacked fire protection.

Interview with Corporate Safety and Emergency Management Specialist (CMEMS), on January 10, 2018, at 9:15 am, confirmed the second floors structural steel lacked fire protection.

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

Findings include:

1. Observation made on January 11, 2018, at 9:28 am, revealed the 2nd floor Spruce Building, near stair tower 5 exit access door, had missing fireproofing on structural beams.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the lack of fireproofing.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair tower enclosures, affecting three of nine floors.

Findings include:

1. Observation made on January 10, 2018, at 11:30 am, revealed the 6th floor Cathcart Building stair tower 5, exit access door failed to positively latch into the frame when tested.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the stair tower door required adjustment.


2. Observation made on January 10, 2018, at 1:40 pm, revealed the 2nd floor Scheidt stairtower 7, inside the stair tower near the exit access door from the second floor, had an unsealed ceiling penetration by a sprinkler pipe.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed penetration of the stair tower.


3. Observation made on January 11, 2018, at 10:45 am, revealed the 8th floor Preston Building stair tower 2, exit access door failed to positively latch into the frame when tested.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the stair tower door required adjustment.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair tower enclosures, affecting two of eleven floors within this component.

Findings include:
1. Observation made on January 11, 2018, at 9:30 am, revealed an unsealed penetration from stair tower 3 into the corridor of the 9th floor landing, approximately 2 inches wide, inside the Spruce Building.
Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed stair tower penetration.


2. Observation made on January 11, 2018, at 9:41 am, revealed inside the first floor Spruce Building stair tower 3, the exit access door failed to positively latch into the frame when tested.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the stair tower door required adjustment.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair towers enclosures, affecting one out of nine levels within this component.

Findings include:

1. Observation made on January 11, 2018, at 9:45 am, revealed the door to stair tower three, at the ninth floor, would not latch due to tape covering the latch mechanism.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the door would not latch.


2. Observation made on January 11, 2018, at 9:48 am, revealed the door to stair tower three, at the ninth floor landing, would not close due to the door being propped open with a wooden wedge.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, at the exit conference, confirmed the door would not close.

Based on observation and interview, it was determined the facility failed to ensure continuous illumination of means of egress, affecting one of ten floors.

Findings include:

1. Observation made on January 10, 2018, at 1:58 am, revealed the sub basement mechanical room had a light out near the exit discharge door.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the light was out.

Based on observation and interview, it was determined the facility failed to ensure continuous illumination of means of egress, affecting one of eleven floors.

Findings include:

1. Observation made on January 11, 2018, at 9:58 am, revealed the first floor Spruce Building stair tower 4, the light was inoperable near the exit discharge door.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the stair tower light was inoperable.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in operable condition, affecting one of three levels.

Findings Include:

1. Observation on January 10, 2018, at 9:45 am, revealed the battery operated emergency lights did not illuminate on the fir and second floors.

Interview with CMEMS on January 10, 2018, at 9:46 am, confirmed the battery operated emergency lights did not illuminate when tested.

Based on observation and interview, it was determined the facility failed to ensure exit signs were continuously illuminated, affecting one of nine floors.

Findings include:

1. Observation made on January 9, 2018, at 1:45 pm, revealed the sub-basement of the Cathcart Building fire pump room had an exit sign that was not illuminated.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the exit sign was not illuminated.

Based on observation and interview, it was determined the facility failed to ensure the fire resistance rating of vertical openings, affecting eleven of eleven floor levels within the building.

Findings include:

1. Observation made on January 11, 2018, between 8:30 am and 2:00 pm, revealed due to the possible presence of friable asbestos inside the Spruce Building, the surveyors were unable to access the the vertical shafts to verify the fire resistance rating was maintained.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the possible existence of friable asbestos inside the shafts.


2. Observation made on January 11, 2018, at 9:50 am, revealed inside the first floor Spruce Building, above elevator SP 3 door, there was an unsealed penetration of the elevator shaft wall.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed elevator shaft penetration.

Based on observation and interview, it was determined the facility failed to maintain access to fire alarm system components, affecting the entire facility.

Findings Include:

1. Observation on January 10 2018, at 10:00 am, confirmed the fire alarm system control panel was located inside the basement, which is leased by another tenant. This hinders access to the area in case of an emergency.

Interview with CMEMS on January 10, 2018, at 10:15 am, confirmed access to the fire alarm system controls is limited.

Based on observation and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting one of nine floors.

Findings include:

1. Observation made on January 9, 2018, at 1:40 pm, revealed a heat sensor cover was detached from it's housing and hanging from wires inside the elevator machine room of the Cathcart Penthouse.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the hanging cover.

Based on observation and interview, it was determined the facility failed to maintain access to automatic sprinkler system components, affecting the entire facility.

Findings Include:

1. Observation on January 10 2018, at 10:00 am, confirmed the sprinkler system controls were located inside the basement, which is leased by another tenant. This hinders access to the area in case of an emergency.

Interview with CMEMS on January 10, 2018, at 10:15 am, confirmed access to sprinkler system controls is limited.

Based on observation and interview, it was determined the facility failed to ensure complete automatic sprinkler protection is provided in buildings classified as fully sprinklered, affecting one of three stair towers within this component.

Findings include:

1. Observation made on January 12, 2018, at 9:30 am, revealed the 1st floor east stair tower lacks sprinkler coverage under the lowest landing of the stair.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, at the exit conference, confirmed the area lacked sprinkler protection.

Based on observation and interview, it was determined the facility failed to ensure complete automatic sprinkler protection, affecting two of nine floors.

Findings include:

1. Observation made on January 9, 2018, at 2:10 pm, revealed an open suspended ceiling section with interstitial space above that lacked sprinkler coverage, inside the central supply room of the Cathcart Building, sub-basement level.
Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the lack of sprinkler coverage.


2. Observation made on January 10, 2018, at 11:20 am, revealed the Schiedt Building basement trash holding room, between Operating Rooms 17 and 18, lacked sprinkler coverage.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the lack of a sprinkler head.

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler system components were inspected, not used to support non-system components, and maintained within a smoke tight assembly, affecting four of twenty seven smoke compartments.

Findings include:

1. Observation made on January 9, 2018, at 1:00 pm, revealed within the Cathcart Penthouse stair 3, the sprinkler stand pipe water pressure gauge was outdated (2010). Verification of recalibration was not available at the time of the inspection.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the sprinkler gauges were beyond the five (5) year service interval.


2. Observation made on January 9, 2018, at 1:55 pm, revealed sub-basement Cathcart patient transport services room had an unsealed ceiling tile penetration which could delay the activation of the automatic sprinkler system.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed ceiling penetration.


3. Observations made on January 10, 2018, between 10:35 am and 11:21 am, revealed unsealed ceiling tile penetrations, which could delay the activation of the automatic sprinkler system, in the following locations:

a. 10:35 am, Preston basement laundry chute room;
b. 11:21 am, Schiedt basement, the room to the left of the trash holding room between operating rooms 17 and 18.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed ceiling penetrations.


4. Observation on January 10, 2018, at 1:25 pm, revealed a large bundle of data cables draped over sprinkler piping, above CA 448 A Scheidt/Cathcart Building connector.

Interview with Safety Officer #1 on January 10, 2018, at 1:26 pm, confirmed the large bundle of wires draped over the sprinkler pipes.

Based on observation and interview, it was determined the facility failed to maintain protection of the automatic sprinkler system, affecting two of seven levels within the facility.

Findings include:

1. Observation made on January 12, 2018, at 10:20 am, revealed the lower level fire pump room, lacked a fire rated corridor door assembly.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, confirmed the fire rated assembly was not complete.


2. Observation made on January 12, 2018 at 10:45 am, revealed the 2nd floor Neurology Department by examination room # 2, had a missing escutcheon plate.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, confirmed the missing escutcheon plate.

Based on observation and interview, it was determined the facility failed to ensure the automatic sprinkler system was inspected and maintained to provide complete coverage, affecting two out of eleven levels within this component.

Findings include:

1. Observation made on January 11, 2018, at 9:18 am, revealed inside the Spruce Building, there were two openings through the upper masonry wall below the ceiling and sprinkler heads located inside mechanical room sp1010. This allows the passage of smoke into the interstitial space of the adjacent bathroom, which could delay activation of the automatic sprinkler system.
Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unsealed opening.


2. Observation made on January 11, 2018, at 10:08 am, revealed the first floor Spruce Building Gamma Knife electric closet, the sprinkler stand pipe water pressure gauge was outdated (2004).

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, onJanuary 11, 2018 at 1:30 pm, confirmed the sprinkler gauge was beyond the five (5) year service interval.

Based on observation and interview, it was determined the facility failed to ensure smoke compartments and travel distances were not excessive, affecting eight of eleven smoke compartments within this component.

Findings Include:

1. Observation made on January 9, 2018, at 9:00 am, revealed the smoke compartments on the second through the ninth floors in the Preston and Schiedt Buildings exceed 22,500 square feet, and travel distance exceed 200 feet.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the size of the smoke compartments and the excessive travel distances.

Based on observation and interview, it was determined the facility failed to maintain smoke compartments within required limits within this component.

Findings include:

1. Observation made on January 11, 2018, between 8:30 am and 2:00 pm, revealed smoke compartments on all floors of the Spruce Building were extended zones exceeding 22,500 square feet.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the excessive smoke compartments.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier partitions, affecting eight of twelve levels.

Findings include:

1. Observation made on January 9, 2018 at 9:00 am, revealed the smoke barrier partitions were incomplete to the deck on the second through the ninth floors of the Preston & Cathcart Buildings.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018, at 1:30 pm, confirmed smoke barrier partitions were incomplete.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers to be smoke resistant, affecting one of twenty-seven smoke compartments within this component.

Findings include:

1. Observation made on January 9, 2018, at 10:40 am, revealed the 8th floor Preston Building smoke barrier doors by the operating rooms failed to close smoke tight into the frame when tested.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the smoke doors were not smoke resistant.

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers to be self closing, affecting one out of one hundred doors within this component.

Findings include:

1. Observation made on January 12, 2018, at 9:45 am, revealed the corridor door in the smoke barrier wall to fourth floor office 405, did not self close and latch when tested.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, confirmed the door did not self close.

Based on observation and interview, it was determined the facility failed to maintain heating, ventilating and air conditioning equipment in operable condition, affecting one out of six levels within this component.

Findings include:

1. Observation made on January 12, 2018, at 9:30 am, revealed the fusible link smoke damper in the rated wall of the Tuttleman Penthouse generator room was covered with spray-on fire insulation, which could impede activation of the damper.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, at the exit conference, confirmed there was a smoke damper obstruction.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of linen chute enclosures, affecting two of twenty-seven smoke compartments within this component.

Findings include:

1. Observation made on January 10, 2018, at 10:20 am, revealed within the 8th floor Cathcart Building linen chute enclosure, the partition across from OR #10 had two unsealed penetrations above the loading door.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the enclosure wall penetrations.

2. Observation on January 10 2018, at 1:10 pm, revealed on the 4th floor inside the Day Stay 4 Schiedt Building, the soiled utility door was not latching in its frame and was not secured to prevent public access to the soiled linen chute located in this room.

Interview with Safety Officer 1 on January 10, 2018, at 1:15 pm, confirmed the linen chute enclosure was not maintained.

Based on observation and interview, it was determined the facility failed to ensure gas cylinder storage areas were maintained properly, affecting one of nine floors.

Findings include:

1. Observation made on January 10, 2018, at 9:50 am, revealed inside the sub-basement of the Cathcart Building manifold cylinder closet, there was a light switch less than five feet above the floor, which could be damaged by a medical gas cylinder.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the light switch was less than five feet above the floor.

Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting one out of 27 smoke zones within this facility.

Findings include:

1. Observation on January 10, 2018, at 10:34 am, revealed an open junction box with exposed wires above the suspended ceiling by elevator labeled PR3 in the Preston Building, basement level.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the exposed internal wiring.

~Refer to the 2011 edition of NFPA 70 National Electrical Code, Section 300.31.

Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting two out of eleven levels within this facility.

Findings include:

1. Observation on January 11, 2018, at 9:01 am, revealed an open junction box with exposed wires next to the roof access ladder inside the power plant room on tenth floor of the Spruce Building.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the exposed internal wiring.


2. Observation on January 11, 2018, at 9:30 am, revealed exposed wires protruding from a conduit and junction elbow inside stair tower two on the ninth floor of the Spruce Building.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the exposed internal wiring.

~Refer to the NFPA 70 National Electrical Code, Section 300.31.

Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical devices, affecting two of twenty-seven smoke compartments within this component.

Findings include:

1. Observation made on January 9, 2018, at 9:20 am, revealed inside the 7th floor Cathcart Building Orthopedic Touch Down Room, there was a microwave plugged into a surge protector.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unauthorized use of an electrical device.


2. Observation made on January 9, 2018, at 1:50 pm, revealed a coffee pot and toaster plugged into a power strip inside the the patient transport room inside the Cathcart Building, sub-basement level.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unauthorized use of the power strip.


3. Observation made on January 10, 2018, at 9:45 am, revealed a coffee pot, microwave and mini-refrigerator plugged into a power strip inside the biomedical shop inside the Cathcart Building, sub-basement level.

Interview at the time of the exit conference with the Senior Director of Facilities Services, Associate Director of Engineering Services and Assistant Director, on January 11, 2018 at 1:30 pm, confirmed the unauthorized use of the power strip.

Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical devices, affecting two out of 10 levels within this component.

Findings include:

1. Observation made on January 12, 2018, at 8:30 am, revealed a microwave plugged into a surge protector inside the 1st floor Nutritionist office.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, confirmed the microwave was plugged into an unauthorized electrical device.


2. Observation made on January 12, 2018, at 8:30am, revealed medical equipment (computer on wheels) plugged into a surge protector inside the first floor Nutritionists office.

Interview with the Director of Physical Plant at the exit conference on January 12, 2018 at 11:30 am, confirmed the use of an unauthorized electrical device.