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

Findings include:

1. Observation made on August 27, 2020, at 10:10 a.m., revealed the ground floor, near the DME private room and hallway, had exposed sturctural steel.

Interview with the general maintenance II specialist, on August 27, 2020, at 10:10 a.m., confirmed the lack of fireproofing.

Based on observation and interview, the facility failed to maintain means of egress, free of all obstructions to full use in case of emergency, on three of six floors.

Findings include:

1. Observation on August 26, 2020, between 2:20 p.m., and 2:25 p.m., revealed the emergency opening mechanisms for the patient room bathroom doors, located on the third floor (North wing), were not functioning properly. The doors were missing the seal mechanism that contacts the emergency door opening hardware, that allows the door to open freely.
A. (2:20 p.m.), emergency opening mechanism on the bathroom door in room 305, was not functioning;
B. (2:22 pm.), emergency opening mechanism on the bathroom door in room 308, was not functioning;
C. (2:25 p.m.), emergency opening mechanism on the bathroom door in room 322, was not functioning.

Interview with the General Maintenance II specialist, on August 26, 2020, at 2:25 p.m., confirmed the above door deficiencies.

2. Observation on August 27, 2020, at 8:03 a.m., 2nd floor, medical surge, had two mobile computers being charged in the corridor.

3. Observation on August 27, 2020, at 9:18 a.m., revealed that on the ground floor, in the storage fast track, a chair was blocking the exit, into the stairwell.

Interview with the general maintenance II specialist, at the times and date listed above, confirmed the corridors were blocked.

Based on observation and interview, it was determined the facility failed to ensure stairways maintained a fire resistance rating, effecting one of six floors, within the facility.

Findings include:

Observation on August 26, 2020, between 1:18 p.m. and 3:15 p.m., revealed unsealed penetrations, above stairway doors, in the following locations:

a. 1:18 p.m., in stairwell #1, above the door, on the inside, had a penetration by a wire;
b. 2:00 p.m., in stairwell #4, the door lacked fire rated hardware;
c. 3:07 p.m., in stairwell #3, the door was only one hour rated.

Interview with the general maintenance II specialist, on August 26, 2020, at the above times, confirmed the listed stairtower issues.

Based on observation and interview, the facility failed to maintain emergency lighting on one of six floors.

Findings include:

1. Observation on August 26, 2020, at 3:05 p.m., revealed the third floor, operating room 1, emergency light malfunctioned at the time of the survey. The " test " button was pressed and released, and the lights remained illuminated. The general maintenance II specialist, removed the emergency light fixture to shut off and test the light, however, the unit failed to function again.

Interview with the general maintenance II specialist, on August 26, 2020, at 3:05 p.m., confirmed the above emergency lighting unit was faulty.

Based on observation and interview, it was determined the facility failed to maintain exit and directional signs in one of six floors

Findings include:

Observation on August 27, 2020, at 8:53 a.m., revealed the following: 1 FD #17, lacked an exit sign to prevent people from going into a non-conforming building, instead of down the stairtower.

Interview with the general maintenance II specialist, on August 27, 2020, at 8:54 a.m., confirmed the lack of an exit sign.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas are self-closing in one of six floors.

Findings include:

Based on observation on August 26, 2020, at 1:05 p.m., the penthouse door #2 to air handlers, was blocked open with an unauthorized device.

Interview with the general maintenance II specialist, on August 26, 2020, at 1:05 p.m., confirmed the door was held open with an unauthorized device.

Based on observation, document review and interview, the facility failed to maintain cooking equipment within one of one cooking areas.

Findings include:

1. Document review on August 26, 2020, at 11:52 a.m., revealed the facility conducted bi-weekly visual checks on the kitchen hood suppression system. However, the facility lacked the required monthly documentation verifying the inspections were being completed.

Interview with the director of engineering and security, on August 26, 2020, at 11:52 a.m., confirmed the facility was lacking the documentation for the monthly inspections.

2.Observation and interview on August 27, 2020, at 10:30 a.m., revealed that two kitchen employees were unaware of the the location of the pull station device to activate the ansul system, in the kitchen area.

Interview with the director of engineering and security, on August 27, 2020, at 10:30a.m., confirmed the above deficiency.

Based on observation and interview, it was determined that the facility failed to remain in accordance with alcohol based hand rub dispenser requirements on one of six floors.

Findings include:

1. Observation on August 26, 2020, at 2:45 p.m., revealed there was an alcohol hand rub dispenser, in a non-sprinklered area mounted to the wall and positioned above carpet, in the anesthesiology office, located on the central wing, of the third floor.

Interview with the general maintenance II specialist, on August 26, 2020, at 2:45 p.m., confirmed the above alcohol based hand rub dispenser deficiency.

Based on observation and interview, the facility failed to maintain smoke barriers on four of six building floors.

Findings include:

1. Observation on August 26, 2020, between 1:18 p.m. and 2:40 p.m., and August 27, 2020, between 8:30 a.m. and 9:45 a.m., revealed the following smoke/fire barriers were deficient:
A. (1:18 p.m.), fourth floor, stairwell #1, 4FD#18, had an unsealed penetration above the door;
B. (1:32 p.m.), fourth floor, stairwell #3, 4FD#7, had an unsealed penetration above the door (data cables);
C. (2:40 p.m.), third floor, fire barrier wall, above 3FD#7 doors, had an unsealed penetration (data cables);
D. (8:30 a.m.), first floor, fire barrier wall, above 1FD#18 doors, had an unsealed penetration (data cables);
E. (8:46 a.m.), first floor, fire barrier wall, above 1FD#17 doors, had an unsealed penetration (data cables);
F. (9:45 a.m.), ground floor, above the fire rated doors, between the East and central wings, had multiple unsealed penetrations (data cables, around sprinkler pipe, open one inch wall section).

Interview with the general maintenance II specialist, on August 26, 2020, at 2:40 p.m. and August 27, 2020, at 9:45 a.m., confirmed the above unsealed penetrations existed.

Based on observation and interview, the facility failed to to have keys to the locked fire extinguisher for instant and immediate use on one of six floors.

Findings include:

Observation on August 27, 2020, at 8:35 a.m., revealed the facility had a manual lock on the fire extinguisher cabinet and all staff who work in behavioral health do not carry keys with them at all times.

Interview with the general maintenance II specialist, on the August 27, 2020, at 8:35 a.m., confirmed staff did not have keys readily available in case of an emergency.

Based on observation and interview it was determined that the facility failed to maintain medical gas master alarm systems on one of six building floors.

Findings include:

1. Observation on August 26, 2020, at 1:10 p.m., revealed the fourth floor, medical gas gauges, were pressurized and the panel/monitoring system was not functioning. The floor is no longer in use, but the medical gas had recently been activated for potential Covid-19 cases. However, the floor remained vacant at the time of the survey.

Interview with the director of engineering and security and general maintenance II specialist, on August 26, 2020, at 1:10 p.m., confirmed the medical gas deficiency above existed.

Based on observation and interview, it was determined the facility failed to maintain/provide piped in medical gas system rooms in one of one room.

Findings include:

Observation on August 27, 2020, at 10:48 a.m., revealed that in the manifold storage room, there was no mechanical ventilation.

Interview with the general maintenance II specialist, on August 27, 2020, at 10:48 a.m., confirmed the lack of mechanical ventilation.

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

Findings include:

1. Observation on August 26, 2020, between 12:55 p.m. and 2:04 p.m., revealed the following electrical deficiencies:
A. (12:55 p.m.), new penthouse (North wing), above the fire alarm chase, had two open junction boxes (missing covers);
B. (1:05 p.m.), old penthouse (Center wing), the electrical breaker panel labeled "EMP1", had a missing fastener that secures the cover to the panel;
C. (1:50 p.m.), fourth floor, (North wing), conference room, had an outlet labeled #1, missing a faceplate;
D. (2:04 p.m.), fourth floor, stairwell #4, the thermostat next to door 4FD#6, had a missing cover plate.

Interview with the general maintenance II specialist, on August 26, 2020, at 2:04 p.m., confirmed the electrical system deficiencies listed above existed.

2. Observation on August 27, 2020, between 8:17 a.m. and 10:24 a.m., revealed the following electrical deficiencies:
A. (8:17 a.m.), second floor, behavioral health, the closet across from the nurses station (old washroom/ dryer closet) had an open junction box;
B. (9:06 a.m.), first floor, North wing nurse station, had an outlet missing the faceplate;
C. (9:21 a.m.), ground floor, outside Fast-Trac, near the patient registration area, had a thermostat hanging by the wire, it was not secured to the wall, and the cover plate was missing;
D. (9:32 a.m.), ground floor, mechanical room, the freezestat temperature sensing device on air handler #1, was missing the cover plate;
E. (9:40 a.m.), ground floor, X-ray room #4, had a section of electrical raceway that was missing the cover and an open section of conduit;
F. (9:56 a.m.), ground floor, the panel labeled "EB" located outside the microbiology urinalysis, was blocked off by a workstation;
G. (10:24 a.m.), basement, employee health assistant office, had an open communication junction box.

Interview with the general maintenance II specialist, on August 27, 2020, at 10:24 a.m., confirmed the electrical system deficiencies listed above existed.

Based on observation and interview, the facility failed to maintain electrical power cords on two of six floors.

Findings include:

1. Observation on August 27, 2020, between 7:44 a.m. and 9:50 a.m., revealed the following electrical power cords were deficient:
A. (7:44 a.m.), second floor, quality directors office, had a Keurig coffee unit plugged into a surge protector;
B. (9:50 a.m.), ground floor, microbiology urinalysis, had a window air conditioning unit plugged into a surge protector.

Interview with the general maintenance II specialist, on August 27, 2020, at 9:50 a.m., confirmed the above power cord deficiencies.