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Based on observation and interview, it was determined the facility failed to maintain stair towers, affecting one of three stair towers within this component.

Findings include:

1. Observation on February 3, 2020, at 1:10 p.m., revealed 1st floor East stair tower had an unsealed penetration around conduit.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the unsealed penetration of the stair tower enclosure.

Based on observation and interview, it was determined the facility failed to maintain exit discharges with a hard packed all-weather travel surface affecting one of three exit discharges.

Findings include:

1. Observation made on February 3, 2020, at 1:37 p.m., revealed the 1st floor exit discharge by admission/examination office traversed through wet and muddy grass before reaching the public way.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the condition of the exit discharge.

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors were enclosed with the required fire resistive rated construction, affecting two of two levels within this component.

Findings include:

Observation made on February 3, 2020, at 2:00 p.m., revealed, within the first floor elevator enclosure, there were two unsealed penetrations of the shaft wall around 2" inch hydraulic fluid supply piping for the elevator and the elevator call button.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the vertical penetrations.

Based on document review and interview, it was determined the facility failed to ensure the fire alarm system was inspected and maintained as required, affecting one of two required inspections.

Findings include:

1. Document review on February 3, 2020, between 8:30 a.m. and 11:00 a.m., revealed semi-annual visual inspection of the fire alarm system was unavailable at the time of inspection.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the documentation was unavailable.

Based on observation and interview, it was determined the facility failed to maintain a fire-resistance rated smoke barrier assembly, affecting one of two levels within this component.

Findings include:

Observation made on February 3, 2020, at 1:15 p.m., revealed 1st floor smoke barrier doors, by rooms 136 and 147, failed to close smoke tight into the door frame when tested.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed smoke barrier separation was not maintained properly.

Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were constructed to resist the passage of smoke, affecting one of two floors.

Findings include:

Observation on February 3, 2020, at 12:45 p.m., revealed, in the vestibule area, the smoke barrier door panic bar had a missing end cap.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the missing end cap.

Based on document review and interview, it was determined the facility failed to complete required inspections of fire rated door assemblies, affecting the entire facility.

Findings include:

1. Document review on February 3, 2020, between 8:30 a.m. and 11:00 a.m., revealed the annual operational fire door inspection report dated July 2, 2019, indicated door failures. Verification door adjustments were not available at the time of inspection.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed corrected documentation of annual fire door inspection was not available.

Based on document review and interview, it was determined the facility failed to complete required inspections of fire rated door assemblies, affecting the entire facility.

Findings include:

1. Document review on February 3, 2020, between 8:30 a.m. and 11:00 a.m., revealed the annual operational fire door inspection report dated July 2, 2019, indicated door failures. Verification of door adjustments were not available at the time of inspection.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed corrected documentation of annual fire door inspection was not available.

Based on observation and interview, it was determined the facility failed to maintain the electrical components to be secured, affecting one of two levels within this component.

Findings include:

Observation made on February 3, 2020, at 1:05 p.m., revealed, inside 1st floor storage room #139, adjacent to the shower, an uncovered junction box exposing the inner live wiring.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the missing protective cover.

Based on observation and interview, it was determined the facility failed to maintain access to electrical panels, affecting one of two floors within this component.

Findings include:

1. Observation on February 3, 2020, at 9:50 am.., revealed, in 1st floor West electrical closet, the electrical panels were blocked by mop carts, wet floor signs and a box.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed access to the electrical panels were blocked.

Based on observation and interview, the facility failed to maintain essential electrical systems, affecting the entire facility.

Findings include:

Observation on February 3, 2020, at 10:35 p.m., revealed indoor emergency generator servicing this building lacked a labeled remote manual stop station, to prevent unintentional operation in accordance with NFPA 110, 5.6.5.6.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the emergency generator lacked labeled remote manual stop station.

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on February 3, 2020, at 2:15 p.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosure.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed there was not a remote manual stop switch located outside of the generator enclosure.

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

Findings include:

Observation made on February 3, 2020, at 2:10 p.m., revealed, inside of the boiler room, there was a heavy duty extension cord daisy chained into an extension cord powering IT equipment.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed the improper use of an electrical device.

Based on observation and interview, it was determined facility personnel failed to properly store medical gas cylinders, affecting one of two levels within this component.

Findings include

Observation made on February 3, 2020, at 1:35 p.m., revealed, within the 1st floor room #119, there were two free standing " E " size oxygen cylinders.

Interview at the exit conference with the Administrator and Maintenance Director on February 3, 2020, at 2:45 p.m., confirmed there were unsecured oxygen cylinders.