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

Findings include:

1. Observation on July 10, 2014, at 8:58 a.m. revealed an unsealed conduit penetration of the common wall, within first floor Medical Records Room.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the two- hour fire resistant ceiling assembly in five locations, affecting two of four floors.

Findings include:

1. Observation on July 9, 2014, between 9:30 a.m. and 1:26 p.m. revealed the following ceiling assembly deficiencies:

a. 9:30 a.m., the large ceiling access panel within the basement-level Bed Repair Room, compromised the fire resistive integrity of the floor slab assembly;
b. 12:15 p.m., a portion of the fire rated ceiling assembly was lacking, within first floor Room 1439;
c. 1:17 p.m., recessed lighting fixtures within the first floor Medical Records lacked bonnet protection;
d. 1:21 p.m., ceiling diffusers within the first floor Medical Records lacked fire dampers;
e. 1:30 p.m., two non-rated access panels within the first floor Medical Records.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the building construction deficiencies.

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

Findings include:

1. Observation on July 9, 2014, at 9:22 a.m. revealed a corridor wall penetration closest to the Lighbulb Room.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the penetration.

Based on observation and interview, it was determined the facility failed to maintain one corridor door, on one of four floors.

Findings include:

1. Observation on July 9, 2014, at 8:20 a.m. revealed the door to basement-level, Room 0832 was held open by unapproved means.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the door was held open.

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

Findings include:

1. Observation on July 9, 2014, between 9:20 a.m. and 1:31 p.m. revealed the following unsealed penetrations:

a. 9:20 a.m., two vertical penetrations of the floor slab assembly were noted within the basement-level exit access corridor closest to the Lightbulb Room.
b. 1:30 p.m., a horizontal penetration of the large shaft enclosure closest to the first floor, Main Entrance.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the unsealed penetrations.

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

Findings include:

1. Observation on July 9, 2014, at 10:46 a.m. revealed an unsealed penetration of the smoke barrier wall within first floor Room 1439, above the suspended ceiling assembly.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the unsealed penetration.

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

Findings include:

1. Observation on July 9, 2014, at 12:02 p.m. revealed the smoke barrier door to first floor Room 1439, lacked a self closing device.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the door lacked a self-closing device.

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

Findings include:

1. Observation on July 9, 2014, between 8:27 a.m. and 9:44 a.m. revealed the following doors to hazardous areas would not close due to contact with the floor:

a. 8:27 a.m., basement-level, Mechanical Room 0839;
b. 8:29 a.m., basement-level, Form Storage Room 0840;
c. 9:44 a.m., basement-level, Mechanical Room 0311.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the doors would not close.

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

Findings include:

1. Observation on July 10, 2014, at 10:12 a.m. revealed the third floor, Third Medical, exit access corridor system was used as a large storage area.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the storage in the corridor.

Based on observation and interview, it was determined the facility failed to maintain illuminated exit signage in one location, on one of four floors.

Findings include:

1. Observation on July 9, 2014, at 8:06 a.m. revealed the facility lacked an exit sign, in the exit access corridor system, in the vicinity of the freight elevator.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the area lacked illuminated exit signage.

Based on observation and interview, it was determined the facility failed to properly install one portable fire extinguisher, on one of four floors.

Findings include:

1. Observation on July 9, 2014, at 10:44 a.m. revealed the fire extinguisher located within the basement-level Electric Shop was installed in excess of sixty inches from the handle to the finished floor.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the fire extinguisher was mounted to high.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one location, on one of four floors of the building.

Findings include:

1. Observation on July 9, 2014, at 9:44 a.m. revealed medical gas piping, within the basement-level Bed Repair Room, lacked shut-off valves at the base of the risers.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the lack of shut-off valves.

Based on observation and interview, it was determined the facility failed to properly install alcohol-based hand rub (ABHR) stations in multiple locations, affecting three of four floors.

Findings include:

1. Observation on July 09, 2014, between 8:55 a.m. and 2:01 p.m. revealed ABHR dispensers were positioned over a source of ignition throughout this component.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the ABHR dispensers were positioned over sources of ignition.

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

Findings include:

1. Observation on July 10, 2014, at 8:58 a.m. revealed an unsealed conduit penetration of the common wall, within first floor Medical Records Room.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to maintain the two- hour fire resistant ceiling assembly in five locations, affecting two of four floors.

Findings include:

1. Observation on July 9, 2014, between 9:30 a.m. and 1:26 p.m. revealed the following ceiling assembly deficiencies:

a. 9:30 a.m., the large ceiling access panel within the basement-level Bed Repair Room, compromised the fire resistive integrity of the floor slab assembly;
b. 12:15 p.m., a portion of the fire rated ceiling assembly was lacking, within first floor Room 1439;
c. 1:17 p.m., recessed lighting fixtures within the first floor Medical Records lacked bonnet protection;
d. 1:21 p.m., ceiling diffusers within the first floor Medical Records lacked fire dampers;
e. 1:30 p.m., two non-rated access panels within the first floor Medical Records.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the building construction deficiencies.

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

Findings include:

1. Observation on July 9, 2014, at 9:22 a.m. revealed a corridor wall penetration closest to the Lighbulb Room.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the penetration.

Based on observation and interview, it was determined the facility failed to maintain one corridor door, on one of four floors.

Findings include:

1. Observation on July 9, 2014, at 8:20 a.m. revealed the door to basement-level, Room 0832 was held open by unapproved means.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the door was held open.

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

Findings include:

1. Observation on July 9, 2014, between 9:20 a.m. and 1:31 p.m. revealed the following unsealed penetrations:

a. 9:20 a.m., two vertical penetrations of the floor slab assembly were noted within the basement-level exit access corridor closest to the Lightbulb Room.
b. 1:30 p.m., a horizontal penetration of the large shaft enclosure closest to the first floor, Main Entrance.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the unsealed penetrations.

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

Findings include:

1. Observation on July 9, 2014, at 10:46 a.m. revealed an unsealed penetration of the smoke barrier wall within first floor Room 1439, above the suspended ceiling assembly.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the unsealed penetration.

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

Findings include:

1. Observation on July 9, 2014, at 12:02 p.m. revealed the smoke barrier door to first floor Room 1439, lacked a self closing device.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the door lacked a self-closing device.

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

Findings include:

1. Observation on July 9, 2014, between 8:27 a.m. and 9:44 a.m. revealed the following doors to hazardous areas would not close due to contact with the floor:

a. 8:27 a.m., basement-level, Mechanical Room 0839;
b. 8:29 a.m., basement-level, Form Storage Room 0840;
c. 9:44 a.m., basement-level, Mechanical Room 0311.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the doors would not close.

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

Findings include:

1. Observation on July 10, 2014, at 10:12 a.m. revealed the third floor, Third Medical, exit access corridor system was used as a large storage area.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the storage in the corridor.

Based on observation and interview, it was determined the facility failed to maintain illuminated exit signage in one location, on one of four floors.

Findings include:

1. Observation on July 9, 2014, at 8:06 a.m. revealed the facility lacked an exit sign, in the exit access corridor system, in the vicinity of the freight elevator.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the area lacked illuminated exit signage.

Based on observation and interview, it was determined the facility failed to properly install one portable fire extinguisher, on one of four floors.

Findings include:

1. Observation on July 9, 2014, at 10:44 a.m. revealed the fire extinguisher located within the basement-level Electric Shop was installed in excess of sixty inches from the handle to the finished floor.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the fire extinguisher was mounted to high.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one location, on one of four floors of the building.

Findings include:

1. Observation on July 9, 2014, at 9:44 a.m. revealed medical gas piping, within the basement-level Bed Repair Room, lacked shut-off valves at the base of the risers.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the lack of shut-off valves.

Based on observation and interview, it was determined the facility failed to properly install alcohol-based hand rub (ABHR) stations in multiple locations, affecting three of four floors.

Findings include:

1. Observation on July 09, 2014, between 8:55 a.m. and 2:01 p.m. revealed ABHR dispensers were positioned over a source of ignition throughout this component.

Exit interview on July 10, 2014, between 12:20 p.m. and 12:40 p.m. with the Facilities Manager confirmed the ABHR dispensers were positioned over sources of ignition.