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Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings between floors, affecting two of three levels within the facility.

Findings include:

1. Observations on July 18, 2018, between 10:50 am and 2:05 pm, revealed unsealed ceiling penetrations in the following locations:

a. 10:50 am, first floor in room 1071;
b. 2:05 pm, ground floor housekeeping storage room 049.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the unsealed penetrations between floors.

Based on observation and interview, it was determined the facility failed to maintain exit access free of obstructions, affecting one of nine smoke compartments within this component.

Findings include:

1. Observation on July 18, 2018, at 10:05 am, revealed in B wing exit stairway at the penthouse level, there were boxes, chairs, and refuse containers stored within the exit stairway.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the stored items within the exit.

Based on observation and interview, it was determined the facility failed to maintain the release of exit egress doors, affecting one of two levels within the facility.

Findings include:

1. Observation on July 18, 2018, at 2:05 pm, revealed ground floor exit egress door 53 required excessive force to open.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the door was hard to open.

Based on observation and interview, it was determined the facility failed to ensure stairways maintained a fire resistance rating, affecting two of three levels within the facility.

Findings include:

1. Observation on July 18, 2018, between 10:20 am and 10:22 am, revealed unsealed penetrations above stairway doors in the following locations:

a. 10:20 am, second floor by 2098;
b. 10:22 am, first floor by 1102.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the unsealed penetrations of the stairways.

Based on observation and interview, it was determined the facility failed to maintain battery back-up lights in operable condition, affecting one of two levels within this component.

Findings include:

1. Observation on July 18, 2018, at 1:35 pm, revealed ground floor mechanical room 0126 had a battery back-up light that failed to illuminate when tested.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the light failed to illuminate.

Based on observation and interview, it was determined the facility failed to ensure openings between floors were enclosed with construction having a fire resistance rating, affecting two of three levels

Findings include:

1. Observation on July 18, 2018, at 8:50 am, revealed on the second floor the corridor access door 238 to the pipe chase and linen chute, was not equipped with an automatic closure and the door did not have a fire resistive rating label.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the access door was not self closing and did not have a fire resistive rating label.

Based on observation and interview, it was determined the facility failed to ensure hazardous area doors were equipped with self-closing or automatic-closing devices and the doors positively latch in the frame, affecting one of three levels within this component.

Findings include:

1. Observation on July 18, 2018, at 9:30 am, revealed on the second floor medical records storage room 2351, the corridor failed to close and positively latch into the door frame,

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the door failed to close properly.

Based on observation and interview, it was determined the facility failed to ensure fire alarm components were maintained in operable condition, affecting three of three levels within this component.

Findings include:

1. Observation on July 18, 2018, at 11:05 am, revealed in the basement the fire control panel was displaying a trouble signal for a smoke detection device.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the fire alarm panel trouble signal.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, with positive latching, affecting one of three levels within this component.

Findings include:

1. Observation made on July 18, 2018, at 10:10 am, revealed the ground floor B-wing staff break room corridor door failed to close completely and positively latch into the frame.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the door failed to latch.

Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls maintained a fire resistance rating, affecting two of nine smoke compartments.

Findings include:

1. Observation on July 18, 2018, at 10:00 am, revealed at C wing above the ceiling at door 282 there was an unsealed data cable conduit penetration of the smoke barrier partition.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the unsealed penetration of the smoke barrier wall.

Based on observation and interview, it was determined the facility failed to ensure linen chutes above the storage or compacting room were enclosed within a continuous fire-rated enclosure, affecting three of three levels.

Findings include:

1. Observation on July 18, 2018, at 8:50 am, revealed on the second floor inside the pipe chase behind door 238, the laundry chute was not enclosed within a continuous fire-rated enclosure. This condition was observed on the second and first floors

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the chute was not enclosed in a continuous fire rated enclosure.


2. Observation made on July 18, 2018, at 10:05 am, revealed the 1st floor A-wing laundry chute access door assembly lacked fire resistive labeling for a minimum of 90-minutes.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the chute was not maintained properly.

Based on observation and interview, it was determined the facility failed to ensure electrical panel cabinets contain accurate and complete circuit directories, affecting one of three levels of this component.

Findings include:

1. Observation on July 18, 2018, at 8:50 am, revealed on the second floor in Laundry room 51A2 the electrical breaker cabinet did not contain an index identifying the purpose/location of the electrical breakers.

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the panel cabinet did contain an index of electrical breakers.

~Refer to NFPA 70, Chapter 4 408.4(A).

Based on observation and interview, it was determined the facility failed to monitor electrical devices for unauthorized use, affecting two of three levels within this component.

Findings include:

1. Observation made on July 18, 2018, between 9:15 am and 10:30 am, revealed the following locations had refrigerators, window air conditioners and microwave ovens plugged into power strips and extension cords:

a. 9:15 am, 1st floor A wing conference room with refrigerator plugged into extension cord;
b. 9:40 am, 1st floor C wing medication room with air conditioner plugged into surge:
c. 10:30 am, ground floor, B wing inside room 040 with microwave oven plugged into surge:

Interview at the exit conference with the Chief Operating Officer and the Facility Fire Marshal on July 18, 2018, at 3:00 pm, confirmed the improper use of electrical devices.