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Based on observation and interview, it was determined the facility failed to maintain emergency lighting in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on July 7, 2021, at 9:45 a.m., revealed the emergency battery lighting, in room 0052 (electrical room), did not illuminate when the test button was depressed.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the emergency lighting was not functional.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in two instances, affecting one of eight smoke compartments.

Findings include:

1. Observation on July 7, 2021, revealed the emergency battery lighting in the following locations did not illuminate when the test button was depressed:

a) 11:15 a.m., in the emergency generator room;
b) 11: 30 a.m., in room 0031.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the emergency lighting was not functional.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in two instances, affecting one of eight smoke compartments.

Findings include:

1. Observation on July 7, 2021, revealed the emergency battery lighting in the following locations did not illuminate when the test button was depressed:

a) 12:35 p.m., in the emergency generator room;
b) 12:40 a.m., in room 0028.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the emergency lighting was not functional.

Based on observation and interview, it was determined the facility failed to install required fire alarm system components in one instance, affecting the entire facility.

Findings include:

1. Observation on July 6, 2021, at 12:55 p.m., revealed there was no automatic smoke or heat detector at the main fire alarm control panel located in Ward Clerk Room 190, on the first floor.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed there was not a smoke detector at the main fire alarm panel.

Based on observation and interview, it was determined the facility failed to install required fire alarm system components in one instance, affecting the entire facility.

Findings include:

1. Observation on July 7, 2021, at 9:42 a.m., revealed there was no automatic smoke or heat detector at the main fire alarm control panel located in administrative office 191, on the first floor.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed there was not a smoke detector at the main fire alarm panel.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of eight smoke compartments throughout the facility.

Findings include:

1. Observation on July 7, 2021, at 1045 a.m., revealed the smoke barrier doors in the basement, near the gym, would not close properly, preventing them from resisting the passage of smoke.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the doors would not resist the passage of smoke.

Based on observation and interview, it was determined the facility failed maintain a two-hour fire resistance rating for one of one emergency generators, affecting the entire facility. Installation shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 19.2.9, NFPA 101.

Findings include:

1. Observation on July 6, 2021, at 12:38 p.m., revealed two penetrations under the ATS in the two-hour rated fire wall, in the room housing the emergency generator.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the penetrations in the two-hour rated enclosure.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in six instances, affecting three of eight smoke compartments.

Findings include:

1. Observation on July 6, 2021, revealed there were electrical outlets, within six feet of a sink, that were not GFCI protected in the following locations:

a) 9:35 a.m., in room 148 on the first floor;
b) 9:40 a.m., in room 149 on the first floor;
c) 9:48 a.m., in room 155 on the first floor;
d) 10:34 a.m., in room 165 on the first floor;
e) 10:35 a.m., in office 181 on the first floor;
f) 11:05 a.m., in restroom 213 in the Ward 2 Dayroom, on the second floor.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the electrical receptacles were not GFCI protected.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles two instances, affecting two of eight smoke compartments.

Findings include:

1. Observation on July 6, 2021, revealed there were electrical outlets, within six feet of a sink, that were not GFCI protected in the following locations:

a) 11:14 a.m., in room 251 on the second floor;
b) 11:42 a.m., in room 138 on the first floor.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m. confirmed the electrical receptacles were not GFCI protected.

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

Findings include:

1. Observation on July 6, 2021, at 11:55 a.m., revealed the facility lacked a remote manual stop station located outside of the generator enclosure.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed there was no remote manual stop station located outside of the generator enclosure.

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

Findings include:

1. Observation on July 6, 2021, at 1:00 p.m., revealed the facility lacked a remote manual stop station located outside of the generator enclosure.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed there was no remote manual stop station located outside of the generator enclosure.

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

Findings include:

1. Observation on July 6, 2021, at 12:35 p.m., revealed the facility lacked remote manual stop stations located outside of the generator enclosures.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed there was no remote manual stop stations located outside of the generator enclosures.

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

Findings include:

1. Observation on July 6, 2021, at 1:00 p.m., revealed the facility lacked remote manual stop stations located outside of the generator enclosures.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed there was no remote manual stop stations located outside of the generator enclosures.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on July 6, 2021, at 12:45 p.m., revealed a refrigerator was connected to a power strip in linen room 003, in the basement.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the misuse of electrical wiring.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on July 7, 2021, at 11:30 a.m., revealed a refrigerator was connected to a power strip in room 170.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the misuse of electrical wiring.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in two instances, affecting two of eight smoke compartments.

Findings include:

1. Observation on July 6, 2021, revealed the following misuse of electrical equipment:

a) 11:30 a.m., a refrigerator was connected to a power strip in room 242;
b) 11:50 a.m., a refrigerator and a microwave were connected to a power strip in the basement activities room.

Interview with the Facility Administrator and Staff on July 7, 2021, at 1:30 p.m., confirmed the misuse of electrical wiring.