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Based upon observation and interview it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations in one of two common wall doors.

Findings include:

1. Observation on May 12, 2015 at between 1:45 pm and 2:00 pm revealed that common wall doors and frame lacked a fire resistance rating at the following locations:
A. Second floor North men's common wall double doors.
B. Third floor North women's common wall double doors.

Interview with the Facility Maintenance Manager on May 12, 2014 at 2:00 pm confirmed the door and frame lacked a fire resistance rating tag.

2. Observation on May 12, 2015 at 11:15 am revealed the common wall had unsealed penetrations of the common wall at the Two North nursing staff area.

Interview with the Facilities Maintenance Manager on May 12, 2015 at 11:15 am confirmed the unsealed penetrations of the common wall.

Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations in seven of more than seventy corridor doors.

Findings include:

Observation on May 12, 2015 between 1:30 pm and 1:50 pm revealed the facility had corridor doors that lacked positive latching in their frames at the following locations:
A. Third floor room 338.
B. Third floor room 326.
C. Third floor room 317.
D. Third floor room 359.
E. Third floor room 393.
F. Third floor day room 330.

Interview with the Facilities Maintenance Manager on May 12, 2015 at 1:50 pm confirmed the above listed corridors lacked positive latching.

Based upon observation and interview, the smoke barriers are constructed to provide at least a one half hour fire resistance rating in two of four smoke barriers.

Findings include:

Observation on May 12, 2015 between 11:10 am and 11:45 am revealed unsealed penetrations of the smoke barrier walls at the following locations:
A. The smoke barrier in Two Men's North between rooms 285 and 286.
B. The smoke barrier in Two Women's South.

Interview with the Facilities Maintenance Manager on May 12, 2015 at 11:45 am confirmed the above listed unsealed smoke barrier penetrations.

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations in three smoke barriers on two floors.

Findings include:

Observation on May 12, 2015 between 11:30 am and 1:45 am revealed that smoke barrier doors did not operate properly at the following locations:
A. Two Women's South smoke barrier doors did not close completely.
B. Three Women's South smoke barrier door 0312 lacked positive latching with the self-closer.
C. Third floor smoke barrier doors by 338 has latching hardware but lacks positive latching with the self-closer.

Interview with the Facilities Maintenance Manager on May 12, 2015 at 1:45 pm confirmed the above listed smoke barrier doors were not operating properly.

Based upon review of documentation and interview, it was determined that the facility failed to perform fire drills as directed by regulations for the entire building.

Findings include:

Observation on May 13, 2015 at 12:15 pm revealed the facility's fire drill documentation were inconclusive in demonstrating fire drills were conducted at varied and unexpected times once per shift per quarter.

Interview with the Facilities Maintenance Manager and the Fire Marshal on May 13, 2015 at 12:15 pm confirmed the facility's fire drills inclusive.

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations in all areas of the entire building.

Findings include:

Observation on May 12, 2015 between 10:45 am and 1:05 pm revealed the facility's portable fire extinguishers are stored on the floor in closets and are not mounted on the wall or in fire extinguisher cabinets at the following locations:
A. Second floor closet 239.
B. Second floor closet 287.
C. Second floor closet 210.
D. Third floor closet 310.

Interview with the Facilities Maintenance Manager on May 12, 2015 at 1:05 pm confirmed the above listed locations had portable fire extinguishers stored on the floor.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies in one of six smoke compartments.

Findings include:

Observation on May 12, 2015 at 11:00 am revealed an open junction box above the suspended ceiling at room 286 on the second floor.

Interview with the Facilities Maintenance Manager on May 12, 2015 at 11:00 am confirmed the open junction box.