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Based on observation and interview, it was determined the facility failed to Maintain the fire resistance of stair towers in one of seven stair towers.

Findings include:

1. Observation on October 22, 2018 at 1:10 pm, revealed, in 2nd floor, C-2 stair tower #5, unsealed mortar joints located above the suspended ceiling.

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement at 2:45 pm, confirmed the unsealed penetrations of the stair tower.

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler components, on one of two levels.

Findings include:

1. Observation on October 22, 2018 at 1:30 pm, revealed a missing sprinkler escutcheon in 2nd floor B-3 chart room.

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement at 2:45 pm, confirmed the missing escutcheon.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings that are resistive to the passage of smoke with no impediments to closing affecting two of eight smoke compartments within this facility.

Findings include:

1. Observation made on October 22, 2018, at 2:10 pm, revealed that 1st floor CI Unit room 115 corridor door would not resist the passage of smoke due to a gap greater than a one half (1/2) inch between the door and door frame.

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement at 2:45 pm, confirmed the door was not resistive to the passage of smoke.

2. Observation made on October 22, 2018, between 1:45 pm and 2:00 pm, revealed that the following corridor doors were obstructed from closing due to items being placed in the swing of door.

a. 1:45 pm, 2nd floor unit B room 414.
b. 2:00 pm, 1st floor extended care unit common room.
c. 2:05 pm, 1st floor B-1 chart room .

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement at 2:45 pm, confirmed the doors were impeded from closing.

Based on documentation review and interview, it was determined that facility failed to maintain heating, ventilation, and air conditioning, affecting the entire facility.

Findings include:

1. Review documents on October 22, 2018 between 8:30 am and 11:00 am, revealed documentation was unavailable verifying fire dampers were maintained verifying fusible links were removed; all dampers were operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary every four to six years.

~Refer to 2012 edition of NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems.

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement, confirmed the air-conditioning and ventilating was not maintained properly.

Based on observation and interview, it was determined the facility failed to protect electrical wiring on one of two levels.

Findings include:

1. Observation on October 22, 2018 at 2:10 pm, revealed, in 1st floor EAC above the ceiling by housekeeping, a junction box missing a cover plate.

~Refer to the NFPA 70 National Electrical Code, Section 300.31.

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement at 2:45 pm, confirmed the missing cover plate.

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of power strips and extension cords on one of two levels within the facility.

Findings include:

1. Observation on October 22, 2018, between 1:00 pm and 1:05 pm, revealed the unauthorized use of power strips and extension cords in the following locations:

a. 1:00 pm, 2nd floor Chart room, an extension cord plugged into an outlet.
b. 1:05 pm, 2nd floor C-2 treatment room, a microwave plugged into a power strip.

Interview at the exit conference on October 22, 2018 at 2:45 pm, with the CEO and the Director of Performance Improvement at 2:45 pm, confirmed the unauthorized use of electrical devices.