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Based on observation and interview, it was determined the facility failed to maintain common walls in five locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, between 11:22 a.m. and 11:44 a.m. revealed the following common wall deficiencies:

a. 11:22 a.m., the common wall doors with the basement Laundry Building required adjustment to latch.
b. 11:26 a.m., basement-level common wall doors with the 12 Component required adjustment to latch.
c. 11:33 a.m., basement-level common wall with the Administration Building lacked a fire rated access panel and two-hour, fire resistive integrity, approximately eighteen inches around the perimeter of the access panel.
d. 11:42 a.m., first floor common wall doors with the Administration Building lacked positive latching.
e. 11:44 a.m., an unsealed penetration of the first floor common wall with the Administration Building.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the common wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain building construction in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, at 10:33 a.m. revealed the basement-level Mechanical Room #1 lacked spray fireproofing in multiple location.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the missing fireproofing.

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

Findings include:

1. Observation on March 10, 2014, at 10:38 a.m. revealed an unsealed penetration of the loading dock corridor wall system.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the corridor wall penetration.

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

Findings include:

1. Observation on March 11, 2014, at 12:55 p.m. revealed the second floor Hospitalist's Room door had miscellaneous penetrations.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting five of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, between 10:44 a.m. and 11:12 a.m. revealed the below vertical opening deficiencies:

a. 10:44 a.m., miscellaneous electrical materials were housed within the basement-level portion of the shaft enclosure, adjacent to the loading dock area.
b. 11:12 a.m., the pipe shaft located within the main stairwell was unenclosed at the basement level.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m., with the Facilities Manager confirmed the vertical opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in three locations, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, between 8:12 a.m. and 11:01 a.m. revealed the below hazardous area enclosure deficiencies:

a. 8:12 a.m., the second floor OR Storage Room door lacked positive latching.
b. 8:13 a.m., the second floor storage room, adjacent to OR Storage, had a hole within the door.
c. 11:01 a.m., the second floor Maternity Copier/Storage Room door lacked a self-closing device.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the hazardous area enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit enclosures in seven locations, affecting seven of ten smoke compartments.

Findings include:

1. Observation between 10:06 a.m. on March 10, 2014, and 11:22 a.m. on March 11, 2014, revealed the following exit enclosure deficiencies:

a. 10:06 a.m. on March 10, 2014, items were stored within the second floor portion of the north stair enclosure.
b. 11:40 a.m. on March 10, 2014, heating and air conditioning, serving the the first floor, west side stair tower, served adjacent areas outside of the enclosure.
c. 11:44 a.m. on March 10, 2014, stair tower doors were removed from the first floor portion of the west stair tower enclosure.
d. 11:46 a.m. on March 10, 2014, the first floor, west stair enclosure required a seal between gypsum board and decking above the suspended ceiling assembly, closest to the Main Lobby.
e. 8:12 a.m. on March 11, 2014, miscellaneous duct work, which does not service the stair enclosure, was located within the second floor portion of the east end stair enclosure.
f. 8:14 a.m. on March 11, 2014, medical gas piping (vacuum, oxygen and medical air) was located within second floor portion of the east end stair enclosure.
g. 11:20 a.m. on March 11, 2014, the second floor, east stair enclosure vision panel, outside of Dietary, was missing two screws.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the stair enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in two locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, at 1:00 p.m. revealed the basement-level Radiology Corridor (Main) required illuminated exit signage in two additional locations.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the exit signage deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, at 1:44 p.m. revealed storage was located within eighteen inches of a sprinkler head assembly within the first floor, Medical Arts Staff Lounge.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the automatic sprinkler deficiency.

Based on observation and interview, it was determined the facility failed to provide adequate sprinkler coverage in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, at 10:26 a.m. revealed the space above the basement-level Facility Supervisor's Office lacked automatic sprinkler protection.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the lack of sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain the heating, ventilation and air conditioning (HVAC) system in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, at 11:55 a.m. revealed a six inch duct, penetrating the fourth floor shaft enclosure wall assembly, closest to the C elevator, lacked a fire damper, retaining angles and access panel where exiting the shaft.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the HVAC system deficiency.

Based on observation and interview, it was determined the facility failed to maintain cooking facilities in four locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, between 8:55 a.m. and 10:55 a.m. revealed the below cooking facilities deficiencies:

a. 8:55 a.m., cafeteria exhaust duct work lacked a one-hour enclosure within the second floor Nursing Supervisor's Office.
b. 8:56 a.m., the cafeteria exhaust duct work access panel within the second floor Nursing Supervisor's Office was inaccessible for cleaning and inspection purposes.
c. 10:49 a.m., the main dietary exhaust duct work access panel was inaccessible for cleaning and inspection purposes (second floor OR area).
d. 10:55 a.m., the main dietary exhaust duct enclosure lacked a fire rated access panel within the enclosure wall (second floor OR area).

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the cooking facilities deficiencies.

Based on observation and interview, it was determined the facility failed to construct and maintain one soiled linen chute, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, at 12:02 p.m. revealed the first floor portion of the soiled linen chute enclosure was not complete above the suspended ceiling assembly within the Financial Services Office.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the incomplete chute enclosure.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in two locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, between 11:05 a.m. and 11:16 a.m. revealed the following medical gas system deficiencies:

a. 11:05 a.m., medical air, vacuum, and oxygen piping lacked shut-off valves at the base of the riser within the basement-level storage room, closest to Security.
b. 11:16 a.m., vacuum piping was located within the basement-level switchgear room.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the medical gas piping deficiencies.

Based on observation and interview, it was determined the facility failed to maintain common walls in five locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, between 11:22 a.m. and 11:44 a.m. revealed the following common wall deficiencies:

a. 11:22 a.m., the common wall doors with the basement Laundry Building required adjustment to latch.
b. 11:26 a.m., basement-level common wall doors with the 12 Component required adjustment to latch.
c. 11:33 a.m., basement-level common wall with the Administration Building lacked a fire rated access panel and two-hour, fire resistive integrity, approximately eighteen inches around the perimeter of the access panel.
d. 11:42 a.m., first floor common wall doors with the Administration Building lacked positive latching.
e. 11:44 a.m., an unsealed penetration of the first floor common wall with the Administration Building.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the common wall deficiencies.

Based on observation and interview, it was determined the facility failed to maintain building construction in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, at 10:33 a.m. revealed the basement-level Mechanical Room #1 lacked spray fireproofing in multiple location.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the missing fireproofing.

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

Findings include:

1. Observation on March 10, 2014, at 10:38 a.m. revealed an unsealed penetration of the loading dock corridor wall system.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the corridor wall penetration.

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

Findings include:

1. Observation on March 11, 2014, at 12:55 p.m. revealed the second floor Hospitalist's Room door had miscellaneous penetrations.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting five of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, between 10:44 a.m. and 11:12 a.m. revealed the below vertical opening deficiencies:

a. 10:44 a.m., miscellaneous electrical materials were housed within the basement-level portion of the shaft enclosure, adjacent to the loading dock area.
b. 11:12 a.m., the pipe shaft located within the main stairwell was unenclosed at the basement level.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m., with the Facilities Manager confirmed the vertical opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in three locations, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, between 8:12 a.m. and 11:01 a.m. revealed the below hazardous area enclosure deficiencies:

a. 8:12 a.m., the second floor OR Storage Room door lacked positive latching.
b. 8:13 a.m., the second floor storage room, adjacent to OR Storage, had a hole within the door.
c. 11:01 a.m., the second floor Maternity Copier/Storage Room door lacked a self-closing device.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the hazardous area enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit enclosures in seven locations, affecting seven of ten smoke compartments.

Findings include:

1. Observation between 10:06 a.m. on March 10, 2014, and 11:22 a.m. on March 11, 2014, revealed the following exit enclosure deficiencies:

a. 10:06 a.m. on March 10, 2014, items were stored within the second floor portion of the north stair enclosure.
b. 11:40 a.m. on March 10, 2014, heating and air conditioning, serving the the first floor, west side stair tower, served adjacent areas outside of the enclosure.
c. 11:44 a.m. on March 10, 2014, stair tower doors were removed from the first floor portion of the west stair tower enclosure.
d. 11:46 a.m. on March 10, 2014, the first floor, west stair enclosure required a seal between gypsum board and decking above the suspended ceiling assembly, closest to the Main Lobby.
e. 8:12 a.m. on March 11, 2014, miscellaneous duct work, which does not service the stair enclosure, was located within the second floor portion of the east end stair enclosure.
f. 8:14 a.m. on March 11, 2014, medical gas piping (vacuum, oxygen and medical air) was located within second floor portion of the east end stair enclosure.
g. 11:20 a.m. on March 11, 2014, the second floor, east stair enclosure vision panel, outside of Dietary, was missing two screws.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the stair enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in two locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, at 1:00 p.m. revealed the basement-level Radiology Corridor (Main) required illuminated exit signage in two additional locations.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the exit signage deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, at 1:44 p.m. revealed storage was located within eighteen inches of a sprinkler head assembly within the first floor, Medical Arts Staff Lounge.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the automatic sprinkler deficiency.

Based on observation and interview, it was determined the facility failed to provide adequate sprinkler coverage in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, at 10:26 a.m. revealed the space above the basement-level Facility Supervisor's Office lacked automatic sprinkler protection.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the lack of sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain the heating, ventilation and air conditioning (HVAC) system in one location, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, at 11:55 a.m. revealed a six inch duct, penetrating the fourth floor shaft enclosure wall assembly, closest to the C elevator, lacked a fire damper, retaining angles and access panel where exiting the shaft.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the HVAC system deficiency.

Based on observation and interview, it was determined the facility failed to maintain cooking facilities in four locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 11, 2014, between 8:55 a.m. and 10:55 a.m. revealed the below cooking facilities deficiencies:

a. 8:55 a.m., cafeteria exhaust duct work lacked a one-hour enclosure within the second floor Nursing Supervisor's Office.
b. 8:56 a.m., the cafeteria exhaust duct work access panel within the second floor Nursing Supervisor's Office was inaccessible for cleaning and inspection purposes.
c. 10:49 a.m., the main dietary exhaust duct work access panel was inaccessible for cleaning and inspection purposes (second floor OR area).
d. 10:55 a.m., the main dietary exhaust duct enclosure lacked a fire rated access panel within the enclosure wall (second floor OR area).

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the cooking facilities deficiencies.

Based on observation and interview, it was determined the facility failed to construct and maintain one soiled linen chute, affecting one of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, at 12:02 p.m. revealed the first floor portion of the soiled linen chute enclosure was not complete above the suspended ceiling assembly within the Financial Services Office.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the incomplete chute enclosure.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in two locations, affecting two of ten smoke compartments.

Findings include:

1. Observation on March 10, 2014, between 11:05 a.m. and 11:16 a.m. revealed the following medical gas system deficiencies:

a. 11:05 a.m., medical air, vacuum, and oxygen piping lacked shut-off valves at the base of the riser within the basement-level storage room, closest to Security.
b. 11:16 a.m., vacuum piping was located within the basement-level switchgear room.

Exit interview on March 12, 2014, between 9:45 a.m. and 10:00 a.m. with the Facilities Manager confirmed the medical gas piping deficiencies.