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Based upon observations and staff interviews on November 26, 2013 between approximately 9:15 AM and 1:30 PM has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.
The findings include, but are not limited to:

1. An electrical fire took place in Mechanical Room 1. Structural members were exposed to high heat conditions.
2. Cracks to the floor above Mechanical Room 1 which is the water pump room.

The above was discussed and acknowledged by the Safety Officer

Based upon observations and staff interviews on November 26, 2013 between approximately 9:15 AM and 1:30 PM has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

1. Doors throughout the facility are being held open in order to supply light and power to parts of the hospital. A fire watch is in place and monitoring the locations that were effected.

The above was discussed and acknowledged by the Safety Officer.

Based upon observation and staff interviews the facility has failed to maintain integrity of the stairwells used for exiting so that they are readily accessible and useable at all times. This may result in residents and staff not being able to exit the building in an emergency.

The findings include but are not limited to:

1. The West Tower stairwell had smoke in it due to electrical power loss of which powers the mechanical system used to keep the stairwell pressurized.

This was acknowledged by the Safety Officer

Based upon observations and staff interviews on November 26, 2013 between approximately 9:15 AM to 1:30 PM has failed to maintain the illumination of the means of egress so that in the event of the failure of a single bulb the means of egress will remain illuminated. This could result in tripping and fall injuries and/or delay in evacuation of residents, staff and/or visitors.

1. Due to the fire in the electrical room, emergency lighting was not available during the emergency.

This was acknowledged by the Safety Officer.

Based upon observations and staff interviews on November 26, 2013 between approximately 9:15 AM to 1:30 PM has failed to maintain the emergency illumination so that during an emergency the means of egress will remain illuminated. This could result in tripping and fall injuries and/or delay in evacuation of residents, staff and/or visitors.

1. Due to the fire in the electrical room, emergency lighting was not available during the emergency.

This was acknowledged by the Safety Officer

Based on observation and staff interviews, the facility failed to maintain proper exit signage. This has the potential to misdirect residents or staff while exiting during an emergency.

During the facility tour on November 26, 2013 from 9:15 AM to 1:30 PM the following exit signs were improperly illuminated:

1. Due to the fire in the electrical room, illuminated exit signage was not available during the emergency.

This was acknowledged by the Safety Officer

Based on observations, the facility failed to maintain the proper operational condition of the fire alarm system. This has the potential of having a non-functional fire alarm system that would expose residents to a fire or smoke environment. The findings are as follows:

During the facility tour on November 26, 2013 from 9:15 AM to 1:30 PM, the following deficiencies were found:

1. Multiple detection devices in the electrical room were damaged due to the electrical fire.
2. Wiring for the fire alarm system in the area of the fire was damaged.

These findings were acknowledged by the Safety Officer.

Based on observations and staff interview during the facility tour on November 26, 2013 from 9:15 AM to 1:30 PM, the facility failed to provide a complete approved sprinkler system in accordance to NFPA 13, Section 5-1.1. This lack of sprinkler coverage has the potential to expose residents to a fire or smoke environment. The findings are as follows:

1. Mechanical Room 1 (area where fire took place was not protected by a sprinkler system)

The facility's Maintenance Director acknowledged these findings.

Based on observation and record review, the facility failed to assure fire extinguishers are properly maintained. This potentially delays a quick response to contain a fire from spreading, exposing residents to fire in the environment.

During the facility tour on November 26, 2013 from 9:15 AM to 1:30 PM, observed multiple fire extinguishers in the area of where the fire had taken place that require servicing due to being used to assist in the extinguishment of the fire.

The Safety officer acknowledged the findings.

Based upon observation and staff interviews, the facility failed to maintain a combustible free area within the mescal room. This has the potential for creating a hazardous environment to both staff and patients in the event of a fire

During the facility tour on November 26, 2013 from 9:15 AM to 1:30 PM, findings include:

1. Mechanical rooms have combustible items stored.

These findings were acknowledged by the Maintenance Director.

Based on observations conducted November 26, 2013 from 9:15 AM to 1:30 PM, the critical branch, life safety branch and the emergency system are all out of service due to the fire that occurred in the main electrical room of the hospital.

The hospital is currently operating 14 generators to provide emergency back up power if needed until repairs are completed

Based on observations conducted November 26, 2013 from 9:15 AM to 1:30 PM, the critical branch, life safety branch and the emergency system are all out of service due to the fire that occurred in the main electrical room of the hospital

Based on observations conducted November 26, 2013 from 9:15 AM to 1:30 PM, the electrical system in the main electrical room of the hospital is out of service due to the fire