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Based on observation and interview, the facility failed to maintain building construction type, potentially affecting the structural integrity of the tower building.

Findings include:

Observation on May 2, 2022, at 1:05 p.m., revealed the ground floor tower generator room had noticeable signs of block wall separation in various locations throughout the room. The south wall had a stair step crack in the joints, approximately nine blocks high to the top concrete block under a main I-beam. The block under that particular I-beam appears to have some spalling and/or paint chipping, potentially from the shifting. The south wall control joint showed signs of separation and the start of a horizontal crack at the top concrete block. On the east wall, above the man door to the electrical room, there was a horizontal crack that followed the door header and a few blocks to the control joint. The electrical room also showed horizontal cracking next to both man doors. Through interview with the director of facilities, it was conveyed that contact was made with the engineer vendor the afternoon following the survey.

Interview with the director of facilities on May 2-3, 2022, at 1:05 p.m., confirmed the above area had visible cracks in the concrete blocks that could potentially affect the structural integrity of the tower building.

Based on observation and interview, the facility failed to maintain accordance with the means of egress on one of seven levels.

Findings include:

Observation on May 5, 2022, at 11:16 a.m., revealed the 2 tower stairwell, located behind the boardroom, had multiple food carts stored in the stairwell, obstructing the egress pathway.

Interview with the director of facilities on May 2, 2022, at 11:16 a.m., confirmed the above exit stair tower landing was used for food cart storage.

Based on observation and interview, it was determined that the facility failed to meet the requirements for doors with self-closing devices on one of six building levels.

Findings include:

1. Observation on May 2, 2022, at 1:50 p.m., revealed multiple doors propped open with a wedge on the first floor main in the neurology department.

Interview with the director of facilities on May 2, 2022, at 1:50 p.m., confirmed the above deficiency.

2. Observation on May 3, 2022, at 10:35 a.m., revealed a door propped open with a wedge on the first floor main, in the medical records scanning center office.

Interview with the director of facilities on May 3, 2022, at 10:35 a.m., confirmed the above deficiency.

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices on three of seven building levels.

Findings include:

1. Observation on May 2, 2022, between 12:16 p.m. and 12:28 p.m., revealed the following self-closing door deficiencies:
A. (12:16 p.m.) 1 tower, SPD storage holding room, had a door propped open with a wedge;
B. (12:28 p.m.) 1 tower, decontamination room, lacked positive latching in the frame with the self-closure device.

Interview with the director of facilities on May 2, 2022, at 12:28 p.m., confirmed the above self-closure door deficiencies.
2. Observation on May 3, 2022, at 9:27 a.m., revealed the 3 tower double doors to the endoscopy suite lacked positive latching within the frame.

Interview with the director of facilities on May 3, 2022, at 9:27 p.m., confirmed the above door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain two of over twenty doors with self-closing devices.

Findings include:

1. Observation on May 3, 2022, between 10:08 a.m. and 12:50 p.m., revealed the following self-closing deficiencies:
A. (10:08 a.m.) 1 north, dietary storage door, was propped open with a wedge;
B. (12:50 p.m.) Fourth floor, 4X-Bldg 03 door, was not latching fully in frame.

Interview with the director of facilities and the maintenance supervisor on May 3, 2022, at 12:50 p.m., confirmed the above door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain emergency lights on one of seven building levels.

Findings include:

Observation on May 2, 2022, at 12:59 p.m., revealed the 1 tower emergency light, located in the switch gear room, had one of two bulbs not illuminate when the test button was pushed.

Interview with the director of facilities on May 2, 2022, at 12:59 p.m., confirmed the above emergency light deficiency.

Based on observation and interview, the facility failed to maintain vertical openings for one of over ten vertical enclosures.

Findings include:

1. Observation on May 3, 2022, at 10:42 a.m., revealed the lower door and office door on the fifth floor stairwell, connecting Surge to hallway, were labeled as 20-minute protection doors, but should be rated for 90 minutes.

Interview with the maintenance supervisor on May 3, 2022, at 10:42 a.m., confirmed the above vertical opening deficiencies.

Based on document review and interview, the facility failed to maintain cooking equipment for one of one cooking area.

Findings include:

1. Document review on May 3, 2022, at 10:53 a.m., revealed the second floor main kitchen's hood suppression system did not have a monthly owner's inspection initialed, in compliance with the manufacturer's maintenance manual.

Interview with the director of facilities on May 3, 2022, at 10:53 a.m., confirmed the lack of "quick-check" documentation.

Based on observation and interview, the facility failed to maintain all fire alarm systems, affecting the entire building.

Findings include:

1. Observation on May 2, 2022, at 12:22 p.m., revealed all fire alarm panels indicated a trouble mode. Through interview, it was conveyed that the elevator strobes and speakers were bypassed due to construction activities at the facility. The facility did not want construction activities to inadvertently activate the alarm system. The alarm panel is still monitored by the facility dispatch center. Also, there are two faults from the additional strobes required from the recent occupancy in the south penthouse. The facility received the new strobes, but installation was not completed at the time of the survey.

Interview with the director of facilities on May 2, 2022, at 12:22 p.m., confirmed the above fire alarm panel deficiencies.

Based on observation and interview, the facility failed to maintain all fire alarm systems, affecting the entire building.

Findings include:

1. Observation on May 2, 2022, at 12:22 p.m., revealed all fire alarm panels indicated a trouble mode. Through interview, it was conveyed that the elevator strobes and speakers were bypassed due to construction activities at the facility. The facility did not want construction activities to inadvertently activate the alarm system. The alarm panel is still monitored by the facility dispatch center. Also, there are two faults from the additional strobes required to be added based on the recent occupancy in the south penthouse. The facility recently received the new strobes, but installation was not completed at the time of the survey.

Interview with the director of facilities on May 2, 2022, at 12:22 p.m., confirmed the above fire alarm panel deficiencies.

Based on observation and interview, the facility failed to maintain all fire alarm systems, affecting the entire building.

Findings include:

1. Observation on May 2, 2022, at 12:22 p.m., revealed all fire alarm panels indicated a trouble mode. Through interview, it was conveyed that the elevator strobes and speakers were bypassed due to construction activities at the facility. The facility did not want construction activities to inadvertently activate the alarm system. The alarm panel was still monitored by the facility dispatch center. Also, there are two faults from the additional strobes required to be added based on the recent occupancy in the south penthouse. The facility received the new strobes, but installation was not completed at the time of the survey.

Interview with the director of facilities on May 2, 2022, at 12:22 p.m., confirmed the above fire alarm panel deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain the sprinkler system on four of six levels.

Findings include:

1. Observation on May 3, 2022, between 9:51 a.m. and 11:30 a.m., revealed the following sprinkler system deficiencies:

A. (9:51 a.m.) First floor, blue oxygen storage room, had a missing escutcheon plate, creating a gap in the ceiling, potentially causing a delay in sprinkler activation;
B. (10:56 a.m.) Second floor, kitchen storage room, had a missing escutcheon plate, creating a gap in the ceiling, potentially causing a delay in sprinkler activation;
C. (11:00 a.m.) Fifth floor, surge area, inpatient cardiac rehab office, had a missing escutcheon plate;
D. (11:16 a.m.) Second floor, main administration, outside assessment room #3, had a missing escutcheon plate, creating a gap in the ceiling, potentially causing a delay in sprinkler activation;
E. (11:30 a.m.) Fourth floor, near 4 south 04 stairwell, had a missing escutcheon plate.

Interview with the director of facilities on May 3, 2022, at 11:30 a.m., confirmed the above sprinkler escutcheon plates were missing.


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2. Observation on May 2, 2022, at 2:15 p.m., revealed the fifth floor south wing housekeeping closet had a missing escutcheon.

Interview with the maintenance supervisor on May 2, 2022, at 2:15 p.m., confirmed the above sprinkler escutcheon plate was missing.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system for one of over 100 rooms.

Findings include:

Observation on May 3, 2022, at 9:34 a.m., revealed the 1 tower pharmacy had a missing escutcheon plate, causing an opening in the ceiling, potentially creating a delay in sprinkler activation.

Interview with the director of facilities on May 3, 2022, at 9:34 a.m., confirmed the above sprinkler escutcheon plate was missing.

Based on observation and interview, the facility failed to maintain the fire sprinkler system for one of over one hundred rooms.

Findings include:

Observation on May 3, 2022, at 10:09 a.m., revealed 1 north, biohazard room, had a ceiling tile removed. Removal of ceiling tiles could delay the activation of the fire sprinkler head.

Interview with the director of facilities on May 3, 2022, at 10:09 a.m., confirmed the above ceiling tile was removed.

Based on observation and interview, the facility failed to maintain corridor doors for one of over one hundred corridor doors.

Findings include:

Observation on May 2, 2022, at 9:51 a.m., revealed 6 tower, patient room 6207, failed to positively latch in the frame.

Interview with the director of facilities on May 2, 2022, at 9:51 a.m., confirmed the above corridor door lacked positive latching.

Based on observation and interview, it was determined that the facility failed to maintain smoke partitions, to resist the passage of smoke, on two of seven building levels.
Findings include:
1. Observation on May 2, 2022, between 9:31 a.m. and 12:19 p.m., revealed the following smoke barrier deficiencies:
A. (9:31 a.m.) 7 tower smoke wall, located above the smoke doors, next to the IT room, had a 3" conduit missing the rated fire caulking;
B. (10:26 a.m.) 5 tower smoke doors, next to the IT room, had a section of the felt seal damaged, preventing the door from closing;
C. (12:19 p.m.) 1 tower, SPD holding fire alarm room, had a 1" penetration in the rated wall.

Interview with the director of facilities on May 2, 2022, at 12:19 p.m., confirmed the above smoke barrier deficiencies existed.

Based on observation and interview, it was determined the facility failed to maintain smoke barriers, to resist the passage of smoke, on one of six levels.

Findings include:

Observation on May 3, 2022, at 11:58 a.m., revealed the fourth floor 4X-Bldg 01 had two unsealed penetrations above the smoke doors.

Interview with the maintenance supervisor on May 3, 2022, at 11:58 a.m., confirmed the above two unsealed penetrations.

Based on observation and interview, the facility failed to maintain smoke barrier doors on one of six levels.

Findings include:

Observation on May 3, 2022, at 11:35 a.m., revealed the fourth floor smoke barrier doors, next to treatment room 12, did not have a rating label affixed to the door.

Interview with the maintenance supervisor on May 3, 2022, at 11:35 a.m., confirmed the above smoke barrier door deficiency.

Based on observation and interview, it was determined that the facility failed to test and inspect fire rated doors on one of six levels.

Findings include:

Observation on May 3, 2022, at 12:14 p.m., revealed the 1 North emergency department waiting room fire barrier doors lacked positive latching due to the lack of a door closure.

Interview with the director of facilities on May 3, 2022, at 12:14 p.m., confirmed the above door lacked positive latching.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, for one of over 100 rooms.

Findings include:

Observation on May 3, 2022, at 10:05 a.m., revealed the 1 north switchgear room had various items stored that obstructed access to the switch gear and breaker panels.

Reference: NFPA 70-110.26(a)

Interview with the director of facilities on May 3, 2022, at 10:05 a.m., confirmed the above deficiency.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on one of seven building levels.

Findings include:

1. Observation on May 2, 2022, at 11:20 a.m., revealed the 2 tower, outside the pre-function glass doors, above the lay-in ceiling tile, had a junction box that was missing the cover.

Reference: NFPA 70-314.28 (C)

Interview with the director of facilities on May 2, 2022, at 11:20 a.m., confirmed the above electrical system deficiency existed.

2. Observation on May 3, 2022, between 9:24 a.m. and 9:42 a.m., revealed the following electrical deficiencies:
A. (9:24 a.m.) 3 tower, endoscopy storage room, had racks blocking access to the electrical panels.
B. (9:42 a.m.) 1 tower, electrical closet next to pharmacy storage, had a breaker panel missing a section of the "dead front"/panel cover.

Reference: NFPA 70-314.28(C) and NFPA 70-110.27

Interview with the director of facilities on May 3, 2022, at 9:42 a.m., confirmed the above electrical system deficiencies existed.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on one of six building levels.

Findings include:

Observation on May 2, 2022, at 1:36 p.m., revealed the south wing penhouse had an open junction box, exposing electrical wires.

Reference: NFPA 70-314.28(C)

Interview with the maintenance supervisor on May 2, 2022, at 1:36 p.m., confirmed the above electrical system deficiency existed.

Based on observation and interview, the facility failed to meet electrical system requirements for one of over fifty rooms.

Findings include:

Observation on May 3, 2022, at 1:45 p.m., revealed the third floor birthing suite, outside room 2, had an outlet not protected by a ground fault circuit interrupter (GFCI) within six feet of the sink.

Interview with the maintenance supervisor on May 3, 2022, at 1:45 p.m., confirmed the outlet was not protected by a GFCI.

Based on observation and interview, it was determined that the facility failed to inspect and maintain electrical equipment power cords and extension cords on four of seven levels.

Findings include:

1. Observation on May 2, 2022, between 9:05 a.m. and 11:02 a.m., revealed the following deficiencies:
A. (9:05 a.m.) 7 tower, neurology service clinical coordinators office, had an electrical cord with insulation separating from the plug end;
B. (9:19 a.m.) 7 tower, ice machine next to oxygen storage, had an electrical cord with insulation separating from the plug end;
C. (10:41 a.m.) 3 tower, anesthesiology lounge, had a Keurig coffee maker plugged into a surge protector;
D. (10:43 a.m.) 3 tower, PICC room, had mobile carts charging with surge protectors plugged into surge protectors;
E. (11:02 a.m.) 2 tower, nurse navigator office, had an extension cord plugged into a surge protector;

Interview with the director of facilities on May 2, 2022, at 11:02 a.m., confirmed the above deficiencies existed.

2. Observation on May 2, 2022, between 9:08 a.m. and 10:05 a.m., revealed the following floors and patient care rooms were utilizing extension cords to supply power to a low voltage transformer:
A. (9:08 a.m.) 7 tower, 26 patient care rooms;
B. (9:40 a.m.) 6 tower, 26 patient care rooms;
C. (10:04 a.m.) 5 tower, 25 patient care rooms.

Interview with the director of facilities on May 2, 2022, at 10:05 a.m., confirmed the extension cord use in the above locations.

Based on observation and interview, the facility failed to maintain electrical equipment for one of over fifty rooms.

Observation on May 3, 2022, at 10:51 a.m., revealed the second floor kitchen had a toaster plugged into a surge protector.

Interview with the director of facilities on May 3, 2022, at 10:51 a.m., confirmed the above electrical equipment deficiency.

Based on observation and interview, the facility failed to maintain electrical equipment for one of over fifty rooms.

Observation on May 3, 2022, at 12:43 p.m., revealed the third floor, X-Wing on-call room, had a space heater plugged into a surge protector.

Interview with the director of facilities on May 3, 2022, at 12:43 p.m., confirmed the above electrical equipment deficiency.

Based on observation and interview, the facility failed to maintain accordance with gas equipment storage requirements on one of six floors.

Findings include:

Observation on May 2, 2022, at 1:28 p.m., revealed the ground floor main addition mechanical room had an unsecured acetylene tank.

Interview with the director of facilities on May 2, 2022, at 1:28 p.m., confirmed the acetylene tank was unsecured at the time of the survey.