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Based on observation and interview, it was determined the facility failed to provide interior finishes of the required flame spread rating, affecting one of five floors of the component.

Findings include:

1. Observation on June 24, 2015, between 10:30 AM and 11:00 AM revealed wood paneling wall finishes throughout the 4th floor. The facility lacked documentation of the flame spread rating of the wood paneling.

Interview with the Chief Operating Officer, Facility Maintenance Manager 1 and the Fire Marshal at 11:00 AM confirmed the facility was unaware of the flame spread rating of the paneling.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one location, on one of four floors within this component.

Findings include:

1. Observation on June 25, 2015, at 10:10 AM revealed the 2nd floor corridor door, to Resident Room #285, would not close and latch in the frame.

Interview with the Facility Maintenance Manager III on June 25, 2015, at 10:10 AM confirmed the door would not close and latch in the frame.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier door openings in three locations, affecting five of ten smoke compartments within this component.

Findings include:

1. Observation on June 25, 2015, between 9:16 AM and 10:15 AM revealed the double smoke barrier doors failed to close and maintain a smoke-tight condition in the following locations:

a) 9:16 AM, 3rd floor smoke barrier double doors, outside Room #371;
b) 10:05 AM, 2nd floor smoke barrier double doors, outside Room #291;
c) 10:15 AM, 2nd floor smoke barrier double doors, outside Room #271.

Interview with the Facility Maintenance Man I and Safety Manager on June 25, 2015, at 10:15 AM confirmed the doors do not close and maintain a smoke-tight condition.

Based on observation and interview, it was determined the facility failed to ensure doors to hazardous areas would properly close and latch in three locations, on two of five floors of the component.

Findings include:

1. Observation on June 24, 2015, between 11:00 AM and 2:25 PM revealed the following:

a) 11:00 AM, the door to the Laundry Chute Room on the ground floor lacked positive latching;
b) 11:50 AM, the door to Medical Records Storage Room #72 on the ground floor was installed with a manual deadbolt only, therefore lacking automatic positive latching;
c) 2:25 PM, the door to Storage Room #175 on the 1st floor, did not have an automatic closing device installed.

Interview with the Facility Maintenance Manager 1 and the Fire Marshal on June 24, 2015 at 2:25 PM confirmed the hazardous area door opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of an exit component enclosure, on two of five floors of the component.

Findings include:

1. Observation on June 25, 2015, between 10:20 AM and 11:45 AM revealed the following unsealed penetrations:

a) 10:20 AM, an unsealed wiring penetration on the 2nd floor, above the door to Firetower #5;
b) 11:45 AM, two unsealed abandoned wire penetrations, above the door to Firetower #1, on the 3rd Floor.

Interview with the Facility Maintenance Manager 1 and the Fire Marshal on June 25, 2015, at 11:45 AM confirmed the penetrations were not sealed.

Based on observation and interview, it was determined the facility failed to ensure exit signs were displayed with continuous illumination in one location, on one of five floors of the component.

Findings include:

1. Observation on June 24, 2015, at 2:15 PM revealed the exit sign, located in Room #146, was not illuminated.

Interview with the Facility Maintenance Manager 1 and the Fire Marshal on June 24, 2015, at 2:15 PM confirmed the exit sign was not illuminated.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of five floors within this component.

Findings include:

1. Observation on June 24, 2015, at 2:00 PM revealed an obstructed sidewall sprinkler, in Communications Room #147 on the 1st floor.

Interview with the Facility Maintenance Manager 1 and the Fire Marshal on June 24, 2015, at 2:00 PM confirmed a large plywood shelf was obstructing the sprinkler.

Based on documentation review, observation and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning (HVAC) system, affecting five of five floors within this component.

Findings include:

1. Review of documentation on June 24, 2015, at 9:10 AM revealed the facility lacked current documentation of the required 4-year exercise and inspection of fire dampers. The facility's last fire damper inspection was completed in May 2011, indicating numerous deficiencies with no evidence of corrective action.

Interview with the Facility Maintenance Manager III on June 24, 2015, at 9:10 AM confirmed the missing documentation of a current inspection and correction of deficiencies from the last inspection.

2. Observation on June 25, 2015, at 12:31 PM revealed the facility was using the 4th floor exit egress corridor as a return air plenum.

Interview with the Facility Maintenance Manager 1 and the Fire Marshal on June 25, 2015, at 12:31 PM confirmed the corridor was used as a return air plenum.

Based on observation and interview, it was determined the facility failed to protect vertical openings in one location, on one of four floors within this component.

Findings include:

1. Observation on June 25, 2015, at 11:50 AM revealed the laundry chute door was obstructed from closing by large amounts of linen, in the basement Soiled Linen Room #14.

Interview with the Facility Maintenance Man I and Safety Manager on June 25, 2015, at 11:50 AM confirmed the laundry chute door was obstructed from closing.

Based on observation and interview, it was determined the facility failed to properly store trash collection receptacles, greater than 32-gallon capacity, in one location, on one of four floors within this component.

Findings include:

1. Observation on June 24, 2015, at 2:00 PM revealed 8 large paper shredding machines located in the 2nd floor Activities Room had a combined capacity of over 100 gallons, stored outside of a protected hazardous storage area.

Interview with Facility Maintenance Manager III on June 24, 2015, at 2:00 PM confirmed the combustibles were stored outside of a protected hazardous storage area.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting five of five floors within this component.

Findings include:

1. Review of documentation on June 24, 2015, at 9:23 AM revealed the lack of documentation verifying the emergency generator was visually inspected weekly, in the last twelve months.

Interview with the Facility Maintenance Manager III on June 24, 2015, at 9:23 AM confirmed the emergency generator weekly visual inspections were not completed.

2. Review of documentation on June 24, 2015, at 9:30 AM revealed the voltage check for the sealed emergency generator battery was not completed weekly, in the last twelve months.

Interview with the Facility Maintenance Manager III on June 24, 2015, at 9:30 AM confirmed the voltage check for the sealed emergency generator battery was not completed weekly.

3. Observation on June 24, 2015, at 1:30 PM revealed the lack of a remote annunciator panel for the emergency generator, at a 24-hour monitored location.

Interview with the Facility Maintenance Manager III on June 24, 2015, at 1:30 PM confirmed the lack of an annunciator panel for the emergency generator.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one location, on one of four floors within this component.

Findings include:

1. Observation on June 24, 2015, at 11:35 AM revealed two sets of two surge protectors daisy-chained in Room #115-6 Nurse's Office.

Interview with the Facility Maintenance Manager III on June 24, 2015 at 11:35 AM confirmed the daisy-chained surge protectors.

Based on observation and interview, it was determined the facility failed to properly install alcohol based hand rub (ABHR) dispensers in one location, on one of five floors within the component.

Findings include:

1. Observation on June 24, 2015, at 2:28 PM revealed an ABHR dispenser was installed over a carpeted floor in Room #159 on the 1st floor. This room is not sprinkler protected.

Interview with the Facility Maintenance Manager 1 and the Fire Marshal on June 24, 2015, at 2:28 PM confirmed the AHRB was installed over the carpet, in a non-sprinklered space.