HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls to a non-conforming building in one location, on one of one floor.

Findings include:

1. Observation on July 25, 2012, at 10:30 AM revealed windows in the common wall, seperating Component 02 (Building 34) from Component 04 (Storage Addition), lacked the required two-hour fire resistance rating.

Interview with the Institution Safety Manager on July 25, 2012, at 10:30 AM confirmed the plain glass windows negated the fire resistance rating of the two hour fire rated common wall.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls to a non-conforming building in one location, on one of one floor.

Findings include:

1. Observation on July 25, 2012, at 10:30 AM revealed windows in the common wall, seperating Component 02 (Building 34) from Component 04 (Storage Addition), lacked the required two-hour fire resistance rating.

Interview with the Institution Safety Manager on July 25, 2012, at 10:30 AM confirmed the plain glass windows negated the fire resistance rating of the two hour fire rated common wall.

Based on observation and interview, it was determined the facility failed to maintain the required construction of corridor walls in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:12 AM revealed a penetration around the door stop, by Basement room 21.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:12 AM confirmed the unsealed penetration.

2. Observation on July 25, 2012, at 10:19 AM revealed unapproved expanding foam was used to seal penetrations of the corridor wall above the suspended ceiling, at the 1st Floor Loading Dock by Dietary.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:19 AM confirmed the use of unapproved expanding foam.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain the required construction of corridor walls in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:12 AM revealed a penetration around the door stop, by Basement room 21.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:12 AM confirmed the unsealed penetration.

2. Observation on July 25, 2012, at 10:19 AM revealed unapproved expanding foam was used to seal penetrations of the corridor wall above the suspended ceiling, at the 1st Floor Loading Dock by Dietary.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:19 AM confirmed the use of unapproved expanding foam.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in 21 locations, on three of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 12:30 PM revealed the door to fourth floor, room 408, was held open with a plastic chock.

Interview with the Institution Safety Manager on July 25, 2012, at 12:30 PM confirmed the door was held open by an unauthorized device.

2. Observation on July 25, 2012, at 12:31 PM revealed the doors to the following fourth floor rooms were equipped with a louver:

a) room 408;
b) room 406;
c) room 402;
d) room 410;
e) room 401;
f) room 420;
g) room 419;
h) room 418;
i) room 414;
j) room 415;
k) room 416;
l) room 417.

Interview with the Institution Safety Manager on July 25, 2012, at 12:31 PM confirmed the doors were equipped with louvers.

3. Observation on July 25, 2012, at 12:35 PM revealed the door, to the third floor Men's Room 311, required a latching adjustment, to properly close and latch in the frame.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the door did not latch.

4. Observation on July 25, 2012, at 1:16 PM revealed the doors, to the following first floor rooms, were equipped with a louver:

a) room 192;
b) room 179;
c) room 186;
d) room 163;
e) room 115;
f) room 128;
g) room 127;
h) room 139.

Interview with the Institution Safety Manager on July 25, 2012, at 1:16 PM confirmed the doors were equipped with louvers.




MKNUP

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in 21 locations, on three of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 12:30 PM revealed the door to fourth floor, room 408, was held open with a plastic chock.

Interview with the Institution Safety Manager on July 25, 2012, at 12:30 PM confirmed the door was held open by an unauthorized device.

2. Observation on July 25, 2012, at 12:31 PM revealed the doors to the following fourth floor rooms were equipped with a louver:

a) room 408;
b) room 406;
c) room 402;
d) room 410;
e) room 401;
f) room 420;
g) room 419;
h) room 418;
i) room 414;
j) room 415;
k) room 416;
l) room 417.

Interview with the Institution Safety Manager on July 25, 2012, at 12:31 PM confirmed the doors were equipped with louvers.

3. Observation on July 25, 2012, at 12:35 PM revealed the door, to the third floor Men's Room 311, required a latching adjustment, to properly close and latch in the frame.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the door did not latch.

4. Observation on July 25, 2012, at 1:16 PM revealed the doors to the following first floor rooms were equipped with a louver:

a) room 192;
b) room 179;
c) room 186;
d) room 163;
e) room 115;
f) room 128;
g) room 127;
h) room 139.

Interview with the Institution Safety Manager on July 25, 2012, at 1:16 PM confirmed the doors were equipped with louvers.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in three locations, on two of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:11 AM revealed the door to Basement room 28, was undercut with a gap greater than one inch to the floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:11 AM confirmed the door was not smoke tight.

2. Observation on July 25, 2012, at 10:17 AM revealed the door, to first floor room 175, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:17 AM confirmed the door was improperly held open.

3. Observation on July 25, 2012, at 10:18 AM revealed the door, to first floor room 174, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:18 AM confirmed the door was improperly held open.




MKNUP

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:17 AM revealed the door, to first floor room 175, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:17 AM confirmed the door was improperly held open.

2. Observation on July 25, 2012, at 10:18 AM revealed the door, to first floor room 174, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:18 AM confirmed the door was improperly held open.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in three locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 12:55 PM revealed the door, to third floor room 3303, would not close and latch, due to the door hitting the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:55 PM confirmed the door would not latch.

2. Observation on July 24, 2012, at 12:56 PM revealed the door, to third floor room 3306, required a latching adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:56 PM confirmed the door would not latch and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on July 24, 2012, at 1:32 PM revealed the door, to third floor room 301, required a closure adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:32 PM confirmed the door would not latch.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in three locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 12:55 PM revealed the door, to third floor room 3303, would not close and latch, due to the door hitting the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:55 PM confirmed the door would not latch.

2. Observation on July 24, 2012, at 12:56 PM revealed the door, to third floor room 3306, required a latching adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:56 PM confirmed the door would not latch and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on July 24, 2012, at 1:32 PM revealed the door, to third floor room 301, required a closure adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:32 PM confirmed the door would not latch.

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of three shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an incomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 11:06 AM revealed the incomplete shaft around the linen chute, in second floor room 246, was not existent.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:06 AM confirmed the chute was not enclosed.

3. Observation on July 25, 2012, at 11:07 AM revealed the pipe chase shaft, in second floor room 247, was not complete around ductwork.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:07 AM confirmed the wall was not complete.

4. Observation and interview on July 25, 2012, at 11:08 AM revealed the doors to the pipe chase within the facility, lacked self closing hardware and were equipped only with a deadbolt.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:08 confirmed the doors did not automatically close and latch.





MKNUP

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of three shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an incomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 11:06 AM revealed the incomplete shaft around the linen chute, in second floor room 246, was not existent.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:06 AM confirmed the chute was not enclosed.

3. Observation on July 25, 2012, at 11:07 AM revealed the pipe chase shaft, in second floor room 247, was not complete around ductwork.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:07 AM confirmed the wall was not complete.

4. Observation and interview on July 25, 2012, at 11:08 AM revealed the doors to the pipe chase within the facility, lacked self closing hardware and were equipped only with a deadbolt.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:08 confirmed the doors did not automatically close and latch.

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of two shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an imcomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 9:21 AM revealed three penetrations to the linen shaft, inside second floor room 287.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:21 AM confirmed the unsealed penetrations.




MKNUP

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of two shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an imcomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 9:21 AM revealed three penetrations to the linen shaft, inside second floor room 287.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:21 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to clearly identify access to exits by readily visible signs in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:40 AM revealed a lit chevron in the exit sign, in first floor room 115, directing egress travel in a direction other than the appropriate direction of exit egress.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:40 AM confirmed the direction of egress travel was not clearly identified.



MKNUP

Based on observation and interview, it was determined the facility failed to clearly identify access to exits by readily visible signs in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:40 AM revealed a lit chevron in the exit sign, in first floor room 115, directing egress travel in a direction other than the appropriate direction of exit egress.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:40 AM confirmed the direction of egress travel was not clearly identified.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 2:08 PM revealed the following unsealed penetrations above the double doors, by second floor room 243:

a) inside one conduit, containing red wires;
b) inside one conduit, containing one black wire;
c) above a group of green and blue wires;
d) around ductwork.

Interview with the Facility Maintenance Manager on July 24, 2012, at 2:08 PM confirmed the unsealed penetrations.

2. Observation on July 25, 2012, at 9:13 AM revealed a penetration above the exit sign, by second floor room 271, inside a 2-inch conduit.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:13 AM confirmed the unsealed penetration.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 2:08 PM revealed the following unsealed penetrations above the double doors, by second floor room 243:

a) inside one conduit, containing red wires;
b) inside one conduit, containing one black wire;
c) above a group of green and blue wires;
d) around ductwork.

Interview with the Facility Maintenance Manager on July 24, 2012, at 2:08 PM confirmed the unsealed penetrations.

2. Observation on July 25, 2012, at 9:13 AM revealed a penetration above the exit sign, by second floor room 271, inside a 2-inch conduit.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:13 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 1:23 PM revealed the double doors by room 196, on the first floor, lacked a coordinator.

Interview with the Institution Safety Manager on July 25, 2012, at 1:23 PM confirmed the doors required a coordinator, to properly close in the frame.




MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 1:23 PM revealed the double doors by room 196, on the first floor, lacked a coordinator.

Interview with the Institution Safety Manager on July 25, 2012, at 1:23 PM confirmed the doors required a coordinator, to properly close in the frame.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:52 AM revealed access panel 223, on the second floor by room 224, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:52 AM confirmed the lack of a self-closing device.




MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:52 AM revealed access panel 223, on the second floor by room 224, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:52 AM confirmed the lack of a self-closing device.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:27 PM revealed the third floor door 3326, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:27 PM confirmed the door did not automatically close.

2. Observation on July 24, 2012, at 1:57 PM revealed the access panel, in the smoke barrier closest to third floor room 339, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:57 PM confirmed the panel did not automatically close.




MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:27 PM revealed the third floor door 3326, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:27 PM confirmed the door did not automatically close.

2. Observation on July 24, 2012, at 1:57 PM revealed the access panel, in the smoke barrier closest to third floor room 339, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:57 PM confirmed the panel did not automatically close.

Based on observation and interview, it was determined that fire-rated enclosures of exit components were not properly protected, in one stairtower throughout the facility.

Findings include:

1. Observation on July 25, 2012, at 12:35 PM revealed two chilled water pipes ran vertically through Fire Tower 3.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the chilled water pipes, located inside the stairtower, did not service the stairtower.




MKNUP

Based on observation and interview, it was determined that fire-rated enclosures of exit components were not properly protected, in one stairtower throughout the facility.

Findings include:

1. Observation on July 25, 2012, at 12:35 PM revealed two chilled water pipes ran vertically through Fire Tower 3.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the chilled water pipes, located inside the stairtower, did not service the stairtower.

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:47 AM revealed three planters, one storage bin and one trash can, located in the exit lobby of Stairwell 180, on the first floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:47 AM confirmed the storage, in the stairwell.

2. Observation on July 25, 2012, at 9:50 AM revealed a container of ice melt stored in Fire Tower 3, on the ground floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:50 AM confirmed the storage in the Fire Tower.




MKNUP

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:47 AM revealed three planters, one storage bin and one trash can, located in the exit lobby of Stairwell 180, on the first floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:47 AM confirmed the storage, in the stairwell.

2. Observation on July 25, 2012, at 9:50 AM revealed a container of ice melt stored in Fire Tower 3, on the ground floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:50 AM confirmed the storage in the Fire Tower.

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested, during the April 23, 2012, annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.





MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested, during the April 23, 2012, annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors located at the top of each elevator shaft were not functionally tested during the April 30, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.





MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors located at the top of each elevator shaft were not functionally tested during the April 30, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested during the April 19, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.





MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested during the April 19, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:20 AM revealed one sprinkler head, in second floor room 287, was missing an escutcheon.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:20 AM confirmed the missing escutcheon.




MKNUP

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:20 AM revealed one sprinkler head, in second floor room 287, was missing an escutcheon.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:20 AM confirmed the missing escutcheon.

Based on observation and interview, it was determined the facility failed to install and maintain the Heating, Ventilating, and Air Conditioning (HVAC) system throughout one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 12:31 PM revealed the facility was using the 4th Floor exit egress corridor as a return air plenum for Rooms 401, 402, 406, 408, 410, 414, 415, 416, 417, 418, 419 and 420.

Interview with the Institution Safety Manager on July 25, 2012, at 12:31 PM confirmed the corridor was used as a return air plenum.

Based on review of documentation and interview, it was determined the facility failed to ensure that semi-monthly inspections and cleanings were performed, on the building's kitchen exhaust system.

Findings include:

1. Review of documentation and interview on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the Kitchen exhaust hood/duct cleaning was completed on an annual basis.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the inspections and cleanings were not completed semi-annually.




MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that semi-monthly inspections and cleanings were performed, on the building's kitchen exhaust system.

Findings include:

1. Review of documentation and interview on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the Kitchen exhaust hood/duct cleaning was completed on an annual basis.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the inspections and cleanings were not completed semi-annually.

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

Findings include:

1. Observation on July 25, 2012, at 10:45 AM revealed a space heater plugged into a surge protector, on the second floor room 236.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:45 AM confirmed the improper use of a surge protector.




MKNUP

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

Findings include:

1. Observation on July 25, 2012, at 10:45 AM revealed a space heater plugged into a surge protector, on the second floor room 236.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:45 AM confirmed the improper use of a surge protector.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:04 PM revealed a junction box lacked a cover plate above the suspended ceiling, by the double doors and Staff Lounge room 388, on the third floor.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:04 PM confirmed the missing cover plate.

2. Observation on July 25, 2012, at 9:10 AM revealed a junction box lacked a cover plate above the suspended ceiling, by the fire alarm strobe light, in the second floor Elevator Lobby.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:10 AM confirmed the missing cover plate.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:04 PM revealed a junction box lacked a cover plate above the suspended ceiling, by the double doors and Staff Lounge room 388, on the third floor.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:04 PM confirmed the missing cover plate.

2. Observation on July 25, 2012, at 9:10 AM revealed a junction box lacked a cover plate above the suspended ceiling, by the fire alarm strobe light, in the second floor Elevator Lobby.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:10 AM confirmed the missing cover plate.

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls to a non-conforming building in one location, on one of one floor.

Findings include:

1. Observation on July 25, 2012, at 10:30 AM revealed windows in the common wall, seperating Component 02 (Building 34) from Component 04 (Storage Addition), lacked the required two-hour fire resistance rating.

Interview with the Institution Safety Manager on July 25, 2012, at 10:30 AM confirmed the plain glass windows negated the fire resistance rating of the two hour fire rated common wall.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls to a non-conforming building in one location, on one of one floor.

Findings include:

1. Observation on July 25, 2012, at 10:30 AM revealed windows in the common wall, seperating Component 02 (Building 34) from Component 04 (Storage Addition), lacked the required two-hour fire resistance rating.

Interview with the Institution Safety Manager on July 25, 2012, at 10:30 AM confirmed the plain glass windows negated the fire resistance rating of the two hour fire rated common wall.

Based on observation and interview, it was determined the facility failed to maintain the required construction of corridor walls in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:12 AM revealed a penetration around the door stop, by Basement room 21.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:12 AM confirmed the unsealed penetration.

2. Observation on July 25, 2012, at 10:19 AM revealed unapproved expanding foam was used to seal penetrations of the corridor wall above the suspended ceiling, at the 1st Floor Loading Dock by Dietary.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:19 AM confirmed the use of unapproved expanding foam.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain the required construction of corridor walls in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:12 AM revealed a penetration around the door stop, by Basement room 21.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:12 AM confirmed the unsealed penetration.

2. Observation on July 25, 2012, at 10:19 AM revealed unapproved expanding foam was used to seal penetrations of the corridor wall above the suspended ceiling, at the 1st Floor Loading Dock by Dietary.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:19 AM confirmed the use of unapproved expanding foam.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in 21 locations, on three of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 12:30 PM revealed the door to fourth floor, room 408, was held open with a plastic chock.

Interview with the Institution Safety Manager on July 25, 2012, at 12:30 PM confirmed the door was held open by an unauthorized device.

2. Observation on July 25, 2012, at 12:31 PM revealed the doors to the following fourth floor rooms were equipped with a louver:

a) room 408;
b) room 406;
c) room 402;
d) room 410;
e) room 401;
f) room 420;
g) room 419;
h) room 418;
i) room 414;
j) room 415;
k) room 416;
l) room 417.

Interview with the Institution Safety Manager on July 25, 2012, at 12:31 PM confirmed the doors were equipped with louvers.

3. Observation on July 25, 2012, at 12:35 PM revealed the door, to the third floor Men's Room 311, required a latching adjustment, to properly close and latch in the frame.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the door did not latch.

4. Observation on July 25, 2012, at 1:16 PM revealed the doors, to the following first floor rooms, were equipped with a louver:

a) room 192;
b) room 179;
c) room 186;
d) room 163;
e) room 115;
f) room 128;
g) room 127;
h) room 139.

Interview with the Institution Safety Manager on July 25, 2012, at 1:16 PM confirmed the doors were equipped with louvers.




MKNUP

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in 21 locations, on three of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 12:30 PM revealed the door to fourth floor, room 408, was held open with a plastic chock.

Interview with the Institution Safety Manager on July 25, 2012, at 12:30 PM confirmed the door was held open by an unauthorized device.

2. Observation on July 25, 2012, at 12:31 PM revealed the doors to the following fourth floor rooms were equipped with a louver:

a) room 408;
b) room 406;
c) room 402;
d) room 410;
e) room 401;
f) room 420;
g) room 419;
h) room 418;
i) room 414;
j) room 415;
k) room 416;
l) room 417.

Interview with the Institution Safety Manager on July 25, 2012, at 12:31 PM confirmed the doors were equipped with louvers.

3. Observation on July 25, 2012, at 12:35 PM revealed the door, to the third floor Men's Room 311, required a latching adjustment, to properly close and latch in the frame.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the door did not latch.

4. Observation on July 25, 2012, at 1:16 PM revealed the doors to the following first floor rooms were equipped with a louver:

a) room 192;
b) room 179;
c) room 186;
d) room 163;
e) room 115;
f) room 128;
g) room 127;
h) room 139.

Interview with the Institution Safety Manager on July 25, 2012, at 1:16 PM confirmed the doors were equipped with louvers.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in three locations, on two of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:11 AM revealed the door to Basement room 28, was undercut with a gap greater than one inch to the floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:11 AM confirmed the door was not smoke tight.

2. Observation on July 25, 2012, at 10:17 AM revealed the door, to first floor room 175, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:17 AM confirmed the door was improperly held open.

3. Observation on July 25, 2012, at 10:18 AM revealed the door, to first floor room 174, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:18 AM confirmed the door was improperly held open.




MKNUP

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:17 AM revealed the door, to first floor room 175, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:17 AM confirmed the door was improperly held open.

2. Observation on July 25, 2012, at 10:18 AM revealed the door, to first floor room 174, was held open with a plastic chock.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:18 AM confirmed the door was improperly held open.

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in three locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 12:55 PM revealed the door, to third floor room 3303, would not close and latch, due to the door hitting the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:55 PM confirmed the door would not latch.

2. Observation on July 24, 2012, at 12:56 PM revealed the door, to third floor room 3306, required a latching adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:56 PM confirmed the door would not latch and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on July 24, 2012, at 1:32 PM revealed the door, to third floor room 301, required a closure adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:32 PM confirmed the door would not latch.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain latching hardware for corridor doors in three locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 12:55 PM revealed the door, to third floor room 3303, would not close and latch, due to the door hitting the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:55 PM confirmed the door would not latch.

2. Observation on July 24, 2012, at 12:56 PM revealed the door, to third floor room 3306, required a latching adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 12:56 PM confirmed the door would not latch and the subsequent correction of the deficiency, at the time of the survey.

3. Observation on July 24, 2012, at 1:32 PM revealed the door, to third floor room 301, required a closure adjustment, to properly close and latch in the frame.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:32 PM confirmed the door would not latch.

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of three shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an incomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 11:06 AM revealed the incomplete shaft around the linen chute, in second floor room 246, was not existent.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:06 AM confirmed the chute was not enclosed.

3. Observation on July 25, 2012, at 11:07 AM revealed the pipe chase shaft, in second floor room 247, was not complete around ductwork.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:07 AM confirmed the wall was not complete.

4. Observation and interview on July 25, 2012, at 11:08 AM revealed the doors to the pipe chase within the facility, lacked self closing hardware and were equipped only with a deadbolt.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:08 confirmed the doors did not automatically close and latch.





MKNUP

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of three shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an incomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 11:06 AM revealed the incomplete shaft around the linen chute, in second floor room 246, was not existent.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:06 AM confirmed the chute was not enclosed.

3. Observation on July 25, 2012, at 11:07 AM revealed the pipe chase shaft, in second floor room 247, was not complete around ductwork.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:07 AM confirmed the wall was not complete.

4. Observation and interview on July 25, 2012, at 11:08 AM revealed the doors to the pipe chase within the facility, lacked self closing hardware and were equipped only with a deadbolt.

Interview with the Facility Maintenance Manager on July 25, 2012, at 11:08 confirmed the doors did not automatically close and latch.

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of two shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an imcomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 9:21 AM revealed three penetrations to the linen shaft, inside second floor room 287.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:21 AM confirmed the unsealed penetrations.




MKNUP

Based on observation and interview, it was determined the facility failed to provide the required fire resistance rating of two shafts, on three of three floors throughout the facility.

Findings include:

1. Observations on July 25, 2012, between 9:21 AM and 2:00 PM, revealed two linen chutes were not enclosed in complete two-hour fire rated shafts; each linen chute was enclosed in an imcomplete shaft, with an open top.

Interview with the Facility Maintenance Manager on July 25, 2012, at 2:00 PM confirmed the incomplete shafts.

2. Observation on July 25, 2012, at 9:21 AM revealed three penetrations to the linen shaft, inside second floor room 287.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:21 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to clearly identify access to exits by readily visible signs in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:40 AM revealed a lit chevron in the exit sign, in first floor room 115, directing egress travel in a direction other than the appropriate direction of exit egress.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:40 AM confirmed the direction of egress travel was not clearly identified.



MKNUP

Based on observation and interview, it was determined the facility failed to clearly identify access to exits by readily visible signs in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:40 AM revealed a lit chevron in the exit sign, in first floor room 115, directing egress travel in a direction other than the appropriate direction of exit egress.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:40 AM confirmed the direction of egress travel was not clearly identified.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 2:08 PM revealed the following unsealed penetrations above the double doors, by second floor room 243:

a) inside one conduit, containing red wires;
b) inside one conduit, containing one black wire;
c) above a group of green and blue wires;
d) around ductwork.

Interview with the Facility Maintenance Manager on July 24, 2012, at 2:08 PM confirmed the unsealed penetrations.

2. Observation on July 25, 2012, at 9:13 AM revealed a penetration above the exit sign, by second floor room 271, inside a 2-inch conduit.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:13 AM confirmed the unsealed penetration.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 2:08 PM revealed the following unsealed penetrations above the double doors, by second floor room 243:

a) inside one conduit, containing red wires;
b) inside one conduit, containing one black wire;
c) above a group of green and blue wires;
d) around ductwork.

Interview with the Facility Maintenance Manager on July 24, 2012, at 2:08 PM confirmed the unsealed penetrations.

2. Observation on July 25, 2012, at 9:13 AM revealed a penetration above the exit sign, by second floor room 271, inside a 2-inch conduit.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:13 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 1:23 PM revealed the double doors by room 196, on the first floor, lacked a coordinator.

Interview with the Institution Safety Manager on July 25, 2012, at 1:23 PM confirmed the doors required a coordinator, to properly close in the frame.




MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of five floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 1:23 PM revealed the double doors by room 196, on the first floor, lacked a coordinator.

Interview with the Institution Safety Manager on July 25, 2012, at 1:23 PM confirmed the doors required a coordinator, to properly close in the frame.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:52 AM revealed access panel 223, on the second floor by room 224, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:52 AM confirmed the lack of a self-closing device.




MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 10:52 AM revealed access panel 223, on the second floor by room 224, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:52 AM confirmed the lack of a self-closing device.

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:27 PM revealed the third floor door 3326, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:27 PM confirmed the door did not automatically close.

2. Observation on July 24, 2012, at 1:57 PM revealed the access panel, in the smoke barrier closest to third floor room 339, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:57 PM confirmed the panel did not automatically close.




MKNUP

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier door openings in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:27 PM revealed the third floor door 3326, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:27 PM confirmed the door did not automatically close.

2. Observation on July 24, 2012, at 1:57 PM revealed the access panel, in the smoke barrier closest to third floor room 339, lacked a self-closing device.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:57 PM confirmed the panel did not automatically close.

Based on observation and interview, it was determined that fire-rated enclosures of exit components were not properly protected, in one stairtower throughout the facility.

Findings include:

1. Observation on July 25, 2012, at 12:35 PM revealed two chilled water pipes ran vertically through Fire Tower 3.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the chilled water pipes, located inside the stairtower, did not service the stairtower.




MKNUP

Based on observation and interview, it was determined that fire-rated enclosures of exit components were not properly protected, in one stairtower throughout the facility.

Findings include:

1. Observation on July 25, 2012, at 12:35 PM revealed two chilled water pipes ran vertically through Fire Tower 3.

Interview with the Institution Safety Manager on July 25, 2012, at 12:35 PM confirmed the chilled water pipes, located inside the stairtower, did not service the stairtower.

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:47 AM revealed three planters, one storage bin and one trash can, located in the exit lobby of Stairwell 180, on the first floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:47 AM confirmed the storage, in the stairwell.

2. Observation on July 25, 2012, at 9:50 AM revealed a container of ice melt stored in Fire Tower 3, on the ground floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:50 AM confirmed the storage in the Fire Tower.




MKNUP

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress in two locations, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:47 AM revealed three planters, one storage bin and one trash can, located in the exit lobby of Stairwell 180, on the first floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:47 AM confirmed the storage, in the stairwell.

2. Observation on July 25, 2012, at 9:50 AM revealed a container of ice melt stored in Fire Tower 3, on the ground floor.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:50 AM confirmed the storage in the Fire Tower.

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested, during the April 23, 2012, annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.





MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested, during the April 23, 2012, annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors located at the top of each elevator shaft were not functionally tested during the April 30, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.





MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors located at the top of each elevator shaft were not functionally tested during the April 30, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested during the April 19, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.





MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that all fire alarm components were inspected annually, for the entire building.

Findings include:

1. Review of documentation on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the analog smoke detectors, located at the top of each elevator shaft, were not functionally tested during the April 19, 2012 annual fire alarm inspection.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the detectors were not tested.

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:20 AM revealed one sprinkler head, in second floor room 287, was missing an escutcheon.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:20 AM confirmed the missing escutcheon.




MKNUP

Based on observation and interview, it was determined the facility failed to provide an automatic sprinkler system which was continuously maintained in a reliable operating condition in one location, on one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 9:20 AM revealed one sprinkler head, in second floor room 287, was missing an escutcheon.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:20 AM confirmed the missing escutcheon.

Based on observation and interview, it was determined the facility failed to install and maintain the Heating, Ventilating, and Air Conditioning (HVAC) system throughout one of four floors of the facility.

Findings include:

1. Observation on July 25, 2012, at 12:31 PM revealed the facility was using the 4th Floor exit egress corridor as a return air plenum for Rooms 401, 402, 406, 408, 410, 414, 415, 416, 417, 418, 419 and 420.

Interview with the Institution Safety Manager on July 25, 2012, at 12:31 PM confirmed the corridor was used as a return air plenum.

Based on review of documentation and interview, it was determined the facility failed to ensure that semi-monthly inspections and cleanings were performed, on the building's kitchen exhaust system.

Findings include:

1. Review of documentation and interview on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the Kitchen exhaust hood/duct cleaning was completed on an annual basis.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the inspections and cleanings were not completed semi-annually.




MKNUP

Based on review of documentation and interview, it was determined the facility failed to ensure that semi-monthly inspections and cleanings were performed, on the building's kitchen exhaust system.

Findings include:

1. Review of documentation and interview on July 24, 2012, between 8:30 AM and 11:30 AM, revealed the Kitchen exhaust hood/duct cleaning was completed on an annual basis.

Interview with the Facility Maintenance Manager on July 24, 2012, at 11:30 AM confirmed the inspections and cleanings were not completed semi-annually.

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

Findings include:

1. Observation on July 25, 2012, at 10:45 AM revealed a space heater plugged into a surge protector, on the second floor room 236.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:45 AM confirmed the improper use of a surge protector.




MKNUP

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

Findings include:

1. Observation on July 25, 2012, at 10:45 AM revealed a space heater plugged into a surge protector, on the second floor room 236.

Interview with the Facility Maintenance Manager on July 25, 2012, at 10:45 AM confirmed the improper use of a surge protector.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:04 PM revealed a junction box lacked a cover plate above the suspended ceiling, by the double doors and Staff Lounge room 388, on the third floor.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:04 PM confirmed the missing cover plate.

2. Observation on July 25, 2012, at 9:10 AM revealed a junction box lacked a cover plate above the suspended ceiling, by the fire alarm strobe light, in the second floor Elevator Lobby.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:10 AM confirmed the missing cover plate.




MKNUP

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and proper use of equipment in two locations, on two of four floors of the facility.

Findings include:

1. Observation on July 24, 2012, at 1:04 PM revealed a junction box lacked a cover plate above the suspended ceiling, by the double doors and Staff Lounge room 388, on the third floor.

Interview with the Facility Maintenance Manager on July 24, 2012, at 1:04 PM confirmed the missing cover plate.

2. Observation on July 25, 2012, at 9:10 AM revealed a junction box lacked a cover plate above the suspended ceiling, by the fire alarm strobe light, in the second floor Elevator Lobby.

Interview with the Facility Maintenance Manager on July 25, 2012, at 9:10 AM confirmed the missing cover plate.