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

Findings include:

1. Observation between 10:01 a.m. on December 27, 2016, and 11:20 a.m. on December 28, 2016, revealed the following building construction deficiencies:

a. 10:01 a.m. on December 27, 2016, sixteen recessed lighting fixtures, located within the first floor, North Wing, lacked bonnet protection (lights were recently replaced).
b. between 10:20 a.m. on December 27, 2016, and 11:20 a.m. on December 28, 2016, numerous "pan-style" ceiling diffusers, located within the rated ceiling assembly, lacked fire blanketing materials.
c. between 10:40 a.m. on December 27, 2016, and 9:40 a.m., on December 28, 2016, ceiling mounted heating units, located at exit discharge locations, lacked bonnet protection.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the building construction deficiencies.

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

Findings include:

1. Observation on December 27, 2016, between 9:49 a.m. and 10:23 a.m. revealed the following:

a. 9:49 a.m., an exit sign within the lower level, North Wing, exit access corridor system directed building occupants from the corridor location, into the T.V./Recreation Lounge, an off-corridor location.
b. 9:55 a.m., the portion of the lower level, North Wing exit access corridor system, located closest to the Connolly Mural, lacked exit signage.
c. 10:23 a.m., exit signage was lacking at each end of the North Module exit access corridor system.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the exit signage deficiencies.

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

Findings include:

1. Observation between 9:40 a.m. on December 27, 2016, and 9:50 a.m. on December 28, 2016, revealed the following:

a. 9:40 a.m. on December 27, 2016, the basement-level, North Wing, Connolly Module Janitor's Closet door lacked a self-closing device (hazardous contents housed within).
b. 9:16 a.m. on December 28, 2016, the first floor, Administration Wing, Copy Room door lacked a self-closing device.
c. 9:50 a.m. on December 28, 2016, the basement level, Medical Records Room door was held open by unapproved means (door chock).

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the hazardous area enclosure deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain the building fire alarm system, affecting two of two floors.

Findings include:

1. Observation on December 28, 2016, at 11:02 a.m. revealed the facility lacked comprehensive, semi-annual, visual fire alarm inspection data.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the facility lacked visual fire alarm inspection data.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting two of two floors.

Findings include:

1. Observation on December 28, 2016, at 11:11 a.m. revealed the following automatic sprinkler system deficiencies:

a. lacked data confirming sprinkler gauges had been changed within the last five years.
b. lacked a five year, internal tank inspection.
c. the last vendor automatic sprinkler and testing data report specified "there is no audible on the water gong at the exterior of the building".

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishing devices in one location, affecting one of two floors.

Findings include:

1. Observation on December 27, 2016, at 9:44 a.m. revealed portable fire extinguishers were stored at floor level within the basement-level, North Wing Nurse's Station.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the portable fire extinguisher deficiency.

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

Findings include:

1. Observation on December 28, 2016, at 9:14 a.m. revealed the first floor, Mail Room door lacked smoke-tight integrity when coupled with the corresponding door frame assembly.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to construct and maintain smoke barrier separation walls in multiple locations, affecting one of two floors.

Findings include:

1. Observation between 10:19 a.m. on December 27, 2016, and 10:05 a.m. on December 28, 2016, revealed the following:

a. 10:19 a.m. on December 27, 2016, the first floor, North Wing smoke barrier separation walls are constructed of a single layer of gypsum board, affixed to conventional wood studding within the attic spaces.
b. 10:20 a.m., on December 27, 2016, conventional wood studs penetrate the attic-level portion of the first floor, North Wing, smoke barrier separation walls at a forty-five degree angle.
c. 10: 22 a.m., on December 27, 2016, one of the North Wing, attic level smoke barrier separation walls is offset between first floor and attic level.
d. 10:23 a.m. on December 27, 2016, large penetrations of the attic-level portion of North Wing smoke barrier separation walls were noted.
e. 10:03 a.m. on December 28, 2016, the attic level portions of the South Wing smoke barrier separation walls are constructed of a single layer of gypsum board affixed to conventional wood studding.
f. 10:04 a.m. on December 28, 2016, there are large penetrations (including cut-out penetrations for the installation of a new duct run) of the attic-level portions of the South Wing smoke barrier separation walls.
g. 10:05 a.m., on December 28, 2016, one of the South Wing, attic level smoke barrier separation walls does not align between gypsum board assembly and concrete masonry unit smoke barrier wall below (the assembly is incomplete in numerous locations across the span of the smoke barrier wall).

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the smoke barrier separation wall deficiencies.

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

Findings include:

1. Observation between 9:42 a.m. and 10:20 a.m. on December 27, 2016, revealed the following smoke barrier separation door deficiencies:

a. 9:42 a.m., the basement level, north wing, smoke barrier door N103 was missing.
b. 9:50 a.m., the basement level, north wing, smoke barrier separation doors closest to the elevator did not fully close.
c. 10:12 a.m., the attic-level smoke barrier separation "man door" was in the "open" position and lacked a self-closing device.
d. 10:20 a.m., the smoke barrier separation doors located closest to the first floor, north wing module did not fully close due to damage.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the smoke barrier separation door deficiencies.

Based on documentation review and interview, it was determined the facility failed to properly maintain the generator set, affecting two of two floors.

Findings include:

1. Observation on December 28, 2016, between 11:20 a.m. and 11:22 a.m. revealed the following:

a. 11:20 a.m., the facility lacked required weekly generator visual inspection data.
b. 11:22 a.m., the facility lacked required weekly battery electrolyte level data.

Exit interview with the Facility Administrator and Facilities Manager on December 28, 2016, between 11:30 a.m. and 11:45 a.m. confirmed the generator set deficiencies.