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Based upon observation and interview, it was determined that the facility failed to maintain a minimum one hour fire resistance rating for structural members within this building component.

Findings include
Observation on January 10, 2012, at 3:10 pm, revealed the building is classified as a one story, Type II(111), protected non-combustible construction. There were exposed structural steel bar joist at the deck inside the electrical closet in Room P132. The facility must verify the UL Design numbers of the ceiling floor/ceiling roof assemblies and maintain a one hour fire-resistance rated assembly within the facility.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the exposed wiring.

Based upon observation and interview, it was determined that the facility failed to provide substantial doors protecting corridor openings in one instance in accordance with regulations.
Findings Include:
Observation on January 10, 2012, at 3:08 pm, revealed the corridor door of room P104 has a hollow core corridor door.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the hollow core door.

Based upon observation and interview, it was determined that the facility failed to maintain corridor doors smoke tight, positive latching, and without impediments to closing the doors in their frames in four instances in accordance with regulations.

Findings include
1. Observation on January 10, 2012, at 1:54 and 2:49 p.m., revealed that the third floor Room M322 - door has visible spacing between the door and its frame.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the corridor door was not smoke tight.

2. Observation made on January 10, 2012, at 2:41 pm, revealed the first floor Room 137E laundry corridor door failed to latch completely when tested.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the corridor door requires adjustment.

3. Observation made on January 10, 2012, at 2:48 pm, revealed the first floor Room M169 corridor door failed to unlatch after closing. The throw hangs up in the catch.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the corridor door requires adjustment to open.

4. Observation made on January 10, 2012, at 2:49 pm, revealed the first floor Room M163 has a damaged finger guard which prevents the door from closing.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the impediment to closing the corridor door.

Based upon observation, it was determined that the facility failed to protect vertical openings in one instance in accordance with regulations.

Findings include:
Observation on January 10, 2012, at 2:00 p.m., revealed that there is an unsealed armor cable through penetration above the third floor center elevator door.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the unsealed annular space around the cable penetration

Based upon observation and interview, it was determined that the facility failed to provide minimum headroom clearance height of not less than 6 ft 8 in., and to arrange for egress out of the locked courtyard gate in two instances in accordance with regulations.

Findings include:
1. Observation on January 10, 2012, at 3:02 pm, revealed the corridor roll down security door has a height clearance of less than 6-ft 8-in.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the lack of height clearance.

2. Observation on January 10, 2012, at 3:15 pm, revealed the exit discharge near Room 123 leads to a courtyard which has a locked gate. Immediately available staff do not have keys to discharge to an area of refuge.

Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the keys for the gate are held by staff not immediately available.

Based upon observation, it was determined that the facility failed to maintain complete unobstructed ceiling assemblies where smoke detectors are installed in two instances in accordance with regulations.

Findings include
1. Observation on January 10, 2012, between 2:07 and 2:10 p.m., revealed that the following rooms had incomplete or damaged ceiling components which may delay smoke detector operation because smoke must then bank down from the deck above before detectors will operate:
a. 2:07 p.m, third floor Room M370 storage and laundry room; and
b. 2:10 p.m., second floor Room M270 storage and laundry room.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the openings in the ceiling.

Based upon observation, it was determined that the facility failed to protect combustible liquid fuel supply piping in one instance in accordance with regulations.

Findings include:
Observation and interview on January 10, 2012, at 3:00 p.m., revealed that the basement boiler room has a large exhaust duct which was subjected to a flooding condition, detached from its support hangars, and collapsed upon the boiler heating oil fuel lines.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the fuel supply lines supporting the weight of a large duct.

Based upon observation, it was determined that the facility failed to maintain protection of ductwork and operable smoke detectors in one instance in accordance with regulations.

Findings include
Observation on January 10, 2012, at 2:21 p.m., revealed the automatic smoke damper located above the corridor smoke barrier door near Room M225, appears to incorporate a rubberized fabric in the assembly. Also, there are missing screws and duct tape is used to hold part of the assembly together.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the condition of the smoke damper.

Based upon observation, it was determined that the facility failed to maintain the emergency generator in one instance in accordance with regulations.

Findings include:
Observation and interview on January 10, 2012, at 3:02 p.m., revealed the exterior emergency generator unit indicator lamps (high energy temperature, overspeed, overcrank, and low oil pressure) failed when tested.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the defective trouble indication lights.

Based upon observation and interview, it was determined that the facility failed to protect live electrical components in one instance in accordance with regulations.

Findings include
Observation on January 10, 2012, at 3:10 pm, revealed the electrical closet in Room P132 has an open electrical junction box near the ceiling.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the exposed wiring.

Based upon observation, it was determined that the facility failed to protect open live electrical parts in one instance in accordance with regulations.

Findings include:
Observation on January 10, 2012, at 1:52 p.m., revealed an open electrical junction box above the ceiling in the third floor staff toilet.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the unprotected open live part.

Based upon observation and interview, it was determined that the facility failed to maintain a minimum one hour fire resistance rating for structural members within this building component.

Findings include
Observation on January 10, 2012, at 3:10 pm, revealed the building is classified as a one story, Type II(111), protected non-combustible construction. There were exposed structural steel bar joist at the deck inside the electrical closet in Room P132. The facility must verify the UL Design numbers of the ceiling floor/ceiling roof assemblies and maintain a one hour fire-resistance rated assembly within the facility.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the exposed wiring.

Based upon observation and interview, it was determined that the facility failed to provide substantial doors protecting corridor openings in one instance in accordance with regulations.
Findings Include:
Observation on January 10, 2012, at 3:08 pm, revealed the corridor door of room P104 has a hollow core corridor door.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the hollow core door.

Based upon observation and interview, it was determined that the facility failed to maintain corridor doors smoke tight, positive latching, and without impediments to closing the doors in their frames in four instances in accordance with regulations.

Findings include
1. Observation on January 10, 2012, at 1:54 and 2:49 p.m., revealed that the third floor Room M322 - door has visible spacing between the door and its frame.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the corridor door was not smoke tight.

2. Observation made on January 10, 2012, at 2:41 pm, revealed the first floor Room 137E laundry corridor door failed to latch completely when tested.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the corridor door requires adjustment.

3. Observation made on January 10, 2012, at 2:48 pm, revealed the first floor Room M169 corridor door failed to unlatch after closing. The throw hangs up in the catch.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the corridor door requires adjustment to open.

4. Observation made on January 10, 2012, at 2:49 pm, revealed the first floor Room M163 has a damaged finger guard which prevents the door from closing.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the impediment to closing the corridor door.

Based upon observation, it was determined that the facility failed to protect vertical openings in one instance in accordance with regulations.

Findings include:
Observation on January 10, 2012, at 2:00 p.m., revealed that there is an unsealed armor cable through penetration above the third floor center elevator door.
Interview at the exit conference with the Director of Quality Management, Director of Facilities and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the unsealed annular space around the cable penetration

Based upon observation and interview, it was determined that the facility failed to provide minimum headroom clearance height of not less than 6 ft 8 in., and to arrange for egress out of the locked courtyard gate in two instances in accordance with regulations.

Findings include:
1. Observation on January 10, 2012, at 3:02 pm, revealed the corridor roll down security door has a height clearance of less than 6-ft 8-in.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the lack of height clearance.

2. Observation on January 10, 2012, at 3:15 pm, revealed the exit discharge near Room 123 leads to a courtyard which has a locked gate. Immediately available staff do not have keys to discharge to an area of refuge.

Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the keys for the gate are held by staff not immediately available.

Based upon observation, it was determined that the facility failed to maintain complete unobstructed ceiling assemblies where smoke detectors are installed in two instances in accordance with regulations.

Findings include
1. Observation on January 10, 2012, between 2:07 and 2:10 p.m., revealed that the following rooms had incomplete or damaged ceiling components which may delay smoke detector operation because smoke must then bank down from the deck above before detectors will operate:
a. 2:07 p.m, third floor Room M370 storage and laundry room; and
b. 2:10 p.m., second floor Room M270 storage and laundry room.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the openings in the ceiling.

Based upon observation, it was determined that the facility failed to protect combustible liquid fuel supply piping in one instance in accordance with regulations.

Findings include:
Observation and interview on January 10, 2012, at 3:00 p.m., revealed that the basement boiler room has a large exhaust duct which was subjected to a flooding condition, detached from its support hangars, and collapsed upon the boiler heating oil fuel lines.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the fuel supply lines supporting the weight of a large duct.

Based upon observation, it was determined that the facility failed to maintain protection of ductwork and operable smoke detectors in one instance in accordance with regulations.

Findings include
Observation on January 10, 2012, at 2:21 p.m., revealed the automatic smoke damper located above the corridor smoke barrier door near Room M225, appears to incorporate a rubberized fabric in the assembly. Also, there are missing screws and duct tape is used to hold part of the assembly together.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the condition of the smoke damper.

Based upon observation, it was determined that the facility failed to maintain the emergency generator in one instance in accordance with regulations.

Findings include:
Observation and interview on January 10, 2012, at 3:02 p.m., revealed the exterior emergency generator unit indicator lamps (high energy temperature, overspeed, overcrank, and low oil pressure) failed when tested.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the defective trouble indication lights.

Based upon observation and interview, it was determined that the facility failed to protect live electrical components in one instance in accordance with regulations.

Findings include
Observation on January 10, 2012, at 3:10 pm, revealed the electrical closet in Room P132 has an open electrical junction box near the ceiling.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the exposed wiring.

Based upon observation, it was determined that the facility failed to protect open live electrical parts in one instance in accordance with regulations.

Findings include:
Observation on January 10, 2012, at 1:52 p.m., revealed an open electrical junction box above the ceiling in the third floor staff toilet.
Interview at the exit conference with the Director of Quality Management, Director of Facilities, and Maintenance Supervisor, on January 10, 2012 at 4:30 p.m., confirmed the unprotected open live part.