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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.
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*Documentation review and interview on November 4, 2015, at 9:45 AM revealed item 1 was not complete.

Interview with the Director of Maintenance on November 4, 2015, at 9:45 AM confirmed item 1 was not complete.

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.
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*Documentation review on November 4, 2015, at 9:30 AM revealed item 1 was not complete. Item 2 is complete.

Interview with the Director of Maintenance on November 4, 2015, at 9:30 AM confirmed item 1 was not complete.

Based on documentation review, observation and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning (HVAC) system, affecting four of four 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.
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*Documentation review on November 4, 2015, at 9:30 AM revealed item 1 was not complete.

Interview with the Director of Maintenance on November 4, 2015, at 9:30 AM confirmed item 1 was not complete.

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.
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*Documentation review on November 4, 2015, at 9:40 AM revealed item 2 was not complete. Items 1 and 3 are complete.

Interview with the Director of Maintenance on November 4, 2015, at 9:40 AM confirmed item 2 was not complete.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting four of four 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.
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*Documentation review on November 4, 2015, at 9:40 AM revealed item 2 was not complete. Items 1 and 3 are complete.

Interview with the Director of Maintenance on November 4, 2015, at 9:40 AM confirmed item 2 was not complete.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting four of four 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.
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*Documentation review on November 4, 2015, at 9:40 AM revealed that item 2 was not complete. Items 1 and 3 are complete.

Interview with the Director of Maintenance on November 4, 2015, at 9:40 AM confirmed item 2 was not complete.