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

Findings include;

1. Observation on March 1, 2023, between 9:36 a.m., and 10:22 a.m., revealed the following:

a. 9:36 a.m., a conduit penetration of common wall with the Core Building, located at the seventh-floor level, to the right of the common wall doors.

b. 10:22 a.m., two conduit penetrations of the common wall with the East Building, at the third floor level, located above the doors.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the common wall deficiencies.

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

Findings include:

1. Observation on March 1, 2023, between 11:10 a.m., and 12:55 p.m., revealed the following structural steel lacked spray fireproofing:

a. 11:10 a.m., within the third floor, Main Mechanical Room, closest to the air handler.
b. 12:30 p.m., at the second floor level, closest to the entrance to the South Building.
c. 12:50 p.m., within the first floor Mechanical Room, closest to the east exit door.
d. 12:55 p.m., within the first floor Mechanical Room, closest to the double exit doors.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the building construction deficiencies.

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

Findings include:

1. Observation on March 1, 2023, at 10:20 a.m., revealed structural steel, located at the third floor level, closest to stair tower P, lacked spray fireproofing.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the building construction deficiency.

Based on observation and interview, it was determined the facility failed to maintain means of egress in one location, affecting one of five floors.

Findings include:

1. Observation on March 1, 2023, at 10:12 a.m., revealed a large amount of dietary items were stored within the third floor, exit access corridor system, located closest to stair tower Q.

Exit interview with Facilities Representative One on March 1, 2023, between 2:15 p.m., and 2:30 p.m.,
confirmed the means of egress deficiency.

Based on observation and interview it was determined the facility failed to maintain doors with self-closing devices affecting two of five floors.

Findings include:

1. Observation on March 1, 2023, between 1:15 p.m. and 2:00 p.m., revealed:

a. 1:15 p.m. - The 4th floor (facility 6th floor) door #1260364 cannot self-close and latch.

b. 2:00 p.m.- The SL1 (facility 2nd floor) Contractor Storage room door lacked a self-closing device.

c. 11:15 a.m. - The SL1 (facility 2nd floor) doors leading to the South Building do not close and latch when tested.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the self-closing door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices affecting three of five floors.

Findings include:

1. Observation on March 1, 2023, between 9:30 a.m. and 11:15 a.m., revealed:

a. 9:30 a.m. - The 5th floor (facility 7th floor) A Stair tower door cannot self-close due to the uneven floor holding the door when opened.

b. 10:40 a.m. - The SL1 (facility 2nd floor) Contractor Storage room door lacked a self-closing device.

c. 11:15 a.m. - The SL1 (facility 2nd floor) common wall doors at the HVI area do not close and latch when tested.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the self-closing door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit stair towers affecting one of three exit stairs within the component.

Findings include:

1. Observation of exit stair towers on March 1, 2023, at 8:25 a.m., revealed deficient headroom, 69" at the lowest point, between SL1 (facility 2nd floor) and 1st floor (facility 3rd floor) in the west exit stair.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the deficient headroom in the west exit stair.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas affecting one of five floors.

Findings include:

1. Observation on March 1, 2023, at 10:38 a.m., revealed an unsealed penetrations located in the SL1 (facility 2nd floor) Contractor Storage room ceiling.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the penetrations.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of five floors.

Findings include:

1. Observation on March 1, 2023, at 10:16 a.m., revealed the third floor, Maple Conference Room storage area door required adjustment to fully latch.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m.,confirmed the hazardous area enclosure deficiency.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers affecting one of approximately twenty fire extinguishers within the component level.

Findings include:

1. Observation on March 1, 2023, at 10:10 a.m., revealed the flush mounted fire extinguisher, located on the 4th floor (facility 6th floor) behind the elevators, lacked signage.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the lack of signage.

Based on observation and interview, it was determined the facility failed to maintain construction of corridor walls, affecting four of four floors.

Findings include:

1. Observation on March 1, 2023, at 12:45 p.m., revealed corridor walls did not extend to the deck above in smoke compartments, as required, based upon lack of automatic sprinkler protection in affected areas.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the building construction deficiencies.

Based on observation it was determined the facility failed to properly construct corridor walls to provide the required one-half hour fire resistance rating in two of five floors.

Findings include:

Observation of corridor walls on March 1, 2023, between 8:30 a.m. and 2:30 p.m., revealed the 4th and 5th (facility 6th and 7th) floor corridor walls are continuous to the underside of the floor/roof deck above, on one side of the corridor only.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the corridor walls.

Based on observation and interview, it was determined the facility failed to maintain corridor doors, affecting one of five floors.

Findings include:

1. Observation on March 1, 2023, at 12:35 p.m., revealed more than 50% of corridor doors located on the 5th floor (facility 7th floor) were held open with trash cans.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the corridor door obstructions.

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

Findings include:

1. Observation on March 1, 2023, at 10:14 a.m., revealed the third floor, Pine Conference Room corridor door required adjustment to fully close, and latch.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain vision panels in corridor walls and doors, affecting four of four floors.

Findings include:

Observation on March 1, 2023, at 1:00 p.m., revealed exit access corridor walls and doors throughout this component possess wired vision panels that are secured in unapproved frames. In addition, the first floor, southwest exit access corridor wall possesses wired glass vision panels, enclosing the communicating stair, which exceed the maximum allowable 25 percent of the enclosure wall.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the vision panel deficiencies.

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

Findings include:

1. Observation on March 1, 2023, at 9:23 a.m., revealed a sprinkler pipe penetration of the seventh floor smoke barrier separation wall, located above the smoke barrier separation doors, closest to PAT.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m.,confirmed the smoke barrier separation wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one-half hour fire resistance rating affecting one of five floors.

Findings include:

1. Observation on March 1, 2023, at 11:15 a.m., revealed unsealed penetrations
above the cross-corridor doors located in the SL1 (facility 2nd floor) at the elevators.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the penetrations.

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

Findings include:

1. Observation on March 1, 2023, at 11:13 a.m., revealed medical gas piping, located within the rear portion of the Main Mechanical Room, lacked labeling.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m.,confirmed the medical gas piping deficiency.

Based on observation and interview it was determined the facility failed to maintain electrical wiring and equipment affecting three of five floors.

Findings include:

1. Observation of electrical wiring and equipment on March 1, 2023, between 12:45 p.m. and 2:10 p.m., revealed:

a. 12:45 p.m. - The 3rd floor (facility 5th floor) Equipment Storage room had a broken electrical receptacle.

b. 1:25 p.m. - The 4th floor (facility 6th floor) corridor near patient room #498 had an electrical junction box with no cover plate.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the exposed electrical wires.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in accordance with NFPA 101 on four of five floors in this component.

Findings include:

1. Observation of electrical wiring and equipment on March 1, 2023, at 8:35 a.m., revealed an electrical junction box with no cover plate located on the 5th floor (facility 7th floor) above the suspended ceiling, near the elevator.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the exposed electrical wires.

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

Findings include:

1. Observation on March 1, 2023, at 9:24 a.m., revealed junction box lacked a cover plate, located above the suspended ceiling assembly, closest to the seventh floor, PAT, smoke barrier separation wall door.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the junction box was open.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage affecting one of five floors.

Findings include:

1. Observation on March 1, 2023, at 2:15 p.m., revealed an unsecured cylinder located in the Medical Gas Storage room.

Exit interview with facility representatives on March 1, 2023, at 2:45 p.m., confirmed the unsecured cylinder.