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Based on observation and interview, it was determined the facility failed to maintain one two-hour fire rated common wall affecting one of three floors in this component.

Findings include:

1. Observation on April 20, 2015, at 10:04 AM, revealed the double set of doors, number 0001, serving the ground floor two-hour fire rated common wall, did not provide positive latching when closed.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the double set of common wall doors did not latch when tested.

Based on observation and interview, it was determined the facility failed to maintain two common walls in three locations, affecting two of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:10 a.m. and 10:27 a.m. revealed the following:

a. 9:10 a.m., penetrations of the common wall with the Administration Building were noted at the basement level, within the corridor system.
b. 9:12 a.m., penetrations of the common wall were noted within basement-level 0017.
c. 10:29 a.m., a penetration of the common wall with the Administration Building was noted closest to the balcony entrance, beyond the access panel, at the fourth floor level.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the common wall penetrations at the basement and fourth floor level.

Based on observation and interview, it was determined the facility failed to maintain common walls in two instances on one of four floors within this component.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 12:15 PM revealed:

a. 9:00 AM - The 4th floor level had an unsealed penetration through the common wall to the Administration building.

b. 12:15 PM - The 2nd floor level had an unsealed penetration above door #212.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the penetrations.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 AM and 2:00 PM revealed the facility exceeds the maximum allowable story height for this type of construction.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the facility exceeds the maximum allowable story height for this type of construction and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 a.m. and 2:00 p.m., revealed the facility exceeds the maximum allowable story height for this type of construction.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the facility exceeds the maximum allowable story height for this type of construction and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.


2. Observation on April 20, 2015, at 9:44 a.m. revealed a load-bearing wall at the basement level to be constructed of unprotected, wooden two by fours (lacked required one-hour integrity.)

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the load-bearing wall at the basement level was constructed of wooden two by fours and lacked one-hour integrity.

3. Observation on April 21, 2015, between 8:20 a.m. and 9:02 a.m. revealed the following:

a. 8:20 a.m., unprotected structural steel was noted within the 3023 chase.
b. 8:22 a.m., recessed lighting fixtures within the 3020 restroom lacked bonnet protection.
c. 8:25 a.m., ceiling diffusers within the 3020 restroom lacked fire dampers.
d. 8:50 a.m., recessed lighting fixtures within the 3023 restroom lacked bonnet protection.
e. 9:02 a.m., recessed lighting fixtures lacked bonnet protection within room 3022.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the unprotected structural steel, recessed lighting fixtures lacking bonnet protection, and ceiling diffusers lacking fire dampers.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 21, 2015, between 10:20 a.m. and 10:24 a.m. revealed the third floor, "second section" corridor walls exhibited open transom devices located above the room doors.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the corridor wall penetrations throughout the third floor, second section.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 1:55 PM revealed the third floor, "second section" corridor walls exhibited open transoms above the corridor doors.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 1:55 PM revealed the third floor, "second section" corridor doors could not latch when closed.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the doors could not latch.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures, affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 AM and 2:00 PM, revealed vertical enclosures, to include exit stair towers, elevator shafts, dumbwaiter shafts and mechanical chases, did not have the required 2-hour fire resistance rating.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed vertical enclosures did not have the required fire resistance rating and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.



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2. Observation on April 20, 2015, between 9:15 a.m. and 1:15 p.m. revealed the following:

a. 9:15 a.m., a penetration of the floor slab assembly was within basement-level 0022.
b. 9:33 a.m., a penetration of the floor slab assembly was noted within basement-level 0005.
c. 1:02 p.m., a penetration of the floor slab assembly was noted within first floor 1082.
d. 1:15 p.m., a penetration of the floor slab assembly was noted within second floor 2105.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the penetrations of the floor slab assemblies at basement, first, and second floor levels.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures, affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 AM and 2:00 PM, revealed vertical enclosures, to include exit stair towers, elevator shafts, dumbwaiter shafts and mechanical chases, did not have the required 2-hour fire resistance rating.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed vertical enclosures did not have the required fire resistance rating and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.




26298

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating in one instance affecting two of seventeen smoke compartments within the component.

Findings include:

1. Observation on April 21, 2015, at 8:00 AM revealed the 1st floor smoke barrier wall was not fully sheathed on both sides of the horizontal area, located above the cross corridor doors #1034.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the incomplete wall.

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 11:12 a.m. revealed the 1022 smoke barrier separation door would not release upon activation of the fire alarm system.

Exit interview with the facility administrator, maintenance one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the smoke barrier separation door would not release upon activation of the building fire alarm system.

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 10:12 a.m. and 10:14 a.m. revealed the following hazardous area enclosure doors lacked self-closing devices.

a. 10:12 a.m., Unit 311 Storage Room.
b. 10:14 a.m., Housekeeping Storage (third floor.)

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the Unit 311 Storage Room and the Housekeeping Storage Room lacked self-closing devices.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures, affecting two of seventeen smoke compartments.

Findings include:

1. Observation on April 20, 2015, between 11:10 AM and 12:30 PM revealed the following rooms with doors lacking self-closing devices.

a. 11:10 AM - 3rd floor Mechanical room #331.

b. 12:28 PM - 2nd floor room #2332, being used for storage.

c. 12:29 PM - 2nd floor room #2333, being used for storage.

d. 12:30 PM - 2nd floor room #2334, being used for storage.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the lack of self-closing devices.

Based on observation and interview the facility failed to maintain exit stair towers in two instances within the component.

Findings include:

1. Observation on April 20, 2015, at 1:40 PM revealed the 1st floor stair tower #1114 had an IT closet located under the lower landing.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the IT closet within a stair tower.

2. Observation on April 21, 2015, at 8:10 AM revealed the Basement level stair tower door #1028 had storage at the bottom of the stairs.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the storage in the stair tower.

Based on observation and interview it was determined the facility failed to provide illumination to one exit discharge path at this component.

Findings include:

1. Observation on April 20, 2015, at 1:30 PM, revealed the 1st floor, East exit lacked adequate continuous lighting, due to a broken light fixture.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the area lacked continuous lighting.

Based on observation and interview, it was determined the facility failed to maintain illuminated exit signage in one of seventeen smoke compartments within the component.

Findings include:

1. Observation on April 20, 2015, at 1:20 PM revealed an illuminated exit sign located above the 1st floor Soiled Linen room door.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the improperly located exit sign.

Based on observation and interview, it was determined the facility failed to install and maintain automatic sprinkler protection in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 9:55 a.m. revealed the basement-level, 0007 Electrical Room lacked automatic sprinkler protection.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the 0007 Electrical Room lacked automatic sprinkler protection.

Based on observation and interview, it was determined the facility failed to install and maintain automatic sprinkler protection in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 10:16 AM revealed the 3rd floor wet area had perforated suspended ceilings with no sprinkler coverage above.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the non-sprinklered area.

2. Observation on April 21, 2015, at 9:30 AM revealed the basement level Electrical rooms did not have sprinkler coverage.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the non-sprinklered area.

Based on documentation review and interview, it was determined the facility failed to conduct quarterly sprinkler testing and inspection within the required time frame affecting four of four floors in this component.

Findings include:

1. Review of quarterly sprinkler testing and inspection documentation on April 20, 2015, at 9:15 AM, revealed the facility had over 150 days between the fourth quarter 2014 and first quarter 2015 inspections.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the quarterly sprinkler inspection and testing intervals were not conducted within the required time frame.

Based on documentation review and interview, it was determined the facility failed to conduct quarterly sprinkler testing and inspection within the required time frame affecting four of four floors in this component.

Findings include:

1. Review of quarterly sprinkler testing and inspection documentation on April 20, 2015, at 9:15 AM, revealed the facility had over 150 days between the fourth quarter 2014 and first quarter 2015 inspections.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the quarterly sprinkler inspection and testing intervals were not conducted within the required time frame .

2. Observation on April 20, 2015, at 10:16 AM revealed the 4th floor Wet Area had sprinkler piping disconnected from the system due to prior freezing.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the disconnected piping.

Based on observation and interview, it was determined the facility failed to maintain one fire extinguisher affecting one of three floors in this component.

Findings include:

1. Observation on April 20, 2015, at 9:57 AM, revealed the first floor fire extinguisher cabinet marker light, near door 1036, was not illuminated.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the marker light for the fire extinguisher, near door 1036, was out.

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 10:53 a.m. revealed multiple cigarette refuse littering the ground in the outdoor, female smoking area.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the smoking regulations deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting four of four floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on April 20, 2015, at 9:30 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting four of four floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on April 20, 2015, at 9:30 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting three of three floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on April 20, 2015, at 9:30 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

Based on observation and interview, it was determined the facility failed to maintain one two-hour fire rated common wall affecting one of three floors in this component.

Findings include:

1. Observation on April 20, 2015, at 10:04 AM, revealed the double set of doors, number 0001, serving the ground floor two-hour fire rated common wall, did not provide positive latching when closed.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the double set of common wall doors did not latch when tested.

Based on observation and interview, it was determined the facility failed to maintain two common walls in three locations, affecting two of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:10 a.m. and 10:27 a.m. revealed the following:

a. 9:10 a.m., penetrations of the common wall with the Administration Building were noted at the basement level, within the corridor system.
b. 9:12 a.m., penetrations of the common wall were noted within basement-level 0017.
c. 10:29 a.m., a penetration of the common wall with the Administration Building was noted closest to the balcony entrance, beyond the access panel, at the fourth floor level.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the common wall penetrations at the basement and fourth floor level.

Based on observation and interview, it was determined the facility failed to maintain common walls in two instances on one of four floors within this component.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 12:15 PM revealed:

a. 9:00 AM - The 4th floor level had an unsealed penetration through the common wall to the Administration building.

b. 12:15 PM - The 2nd floor level had an unsealed penetration above door #212.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the penetrations.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 AM and 2:00 PM revealed the facility exceeds the maximum allowable story height for this type of construction.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the facility exceeds the maximum allowable story height for this type of construction and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 a.m. and 2:00 p.m., revealed the facility exceeds the maximum allowable story height for this type of construction.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the facility exceeds the maximum allowable story height for this type of construction and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.


2. Observation on April 20, 2015, at 9:44 a.m. revealed a load-bearing wall at the basement level to be constructed of unprotected, wooden two by fours (lacked required one-hour integrity.)

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the load-bearing wall at the basement level was constructed of wooden two by fours and lacked one-hour integrity.

3. Observation on April 21, 2015, between 8:20 a.m. and 9:02 a.m. revealed the following:

a. 8:20 a.m., unprotected structural steel was noted within the 3023 chase.
b. 8:22 a.m., recessed lighting fixtures within the 3020 restroom lacked bonnet protection.
c. 8:25 a.m., ceiling diffusers within the 3020 restroom lacked fire dampers.
d. 8:50 a.m., recessed lighting fixtures within the 3023 restroom lacked bonnet protection.
e. 9:02 a.m., recessed lighting fixtures lacked bonnet protection within room 3022.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the unprotected structural steel, recessed lighting fixtures lacking bonnet protection, and ceiling diffusers lacking fire dampers.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 21, 2015, between 10:20 a.m. and 10:24 a.m. revealed the third floor, "second section" corridor walls exhibited open transom devices located above the room doors.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the corridor wall penetrations throughout the third floor, second section.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 1:55 PM revealed the third floor, "second section" corridor walls exhibited open transoms above the corridor doors.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the corridor wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in multiple locations, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 9:00 AM and 1:55 PM revealed the third floor, "second section" corridor doors could not latch when closed.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the doors could not latch.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures, affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 AM and 2:00 PM, revealed vertical enclosures, to include exit stair towers, elevator shafts, dumbwaiter shafts and mechanical chases, did not have the required 2-hour fire resistance rating.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed vertical enclosures did not have the required fire resistance rating and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.



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2. Observation on April 20, 2015, between 9:15 a.m. and 1:15 p.m. revealed the following:

a. 9:15 a.m., a penetration of the floor slab assembly was within basement-level 0022.
b. 9:33 a.m., a penetration of the floor slab assembly was noted within basement-level 0005.
c. 1:02 p.m., a penetration of the floor slab assembly was noted within first floor 1082.
d. 1:15 p.m., a penetration of the floor slab assembly was noted within second floor 2105.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the penetrations of the floor slab assemblies at basement, first, and second floor levels.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures, affecting four of four floors in this component.

Findings include:

1. Observation on April 20, 2015, between 8:30 AM and 2:00 PM, revealed vertical enclosures, to include exit stair towers, elevator shafts, dumbwaiter shafts and mechanical chases, did not have the required 2-hour fire resistance rating.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed vertical enclosures did not have the required fire resistance rating and identified the facility has an acceptable FSES conducted on 4/20/2015, addressing this issue.




26298

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating in one instance affecting two of seventeen smoke compartments within the component.

Findings include:

1. Observation on April 21, 2015, at 8:00 AM revealed the 1st floor smoke barrier wall was not fully sheathed on both sides of the horizontal area, located above the cross corridor doors #1034.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the incomplete wall.

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 11:12 a.m. revealed the 1022 smoke barrier separation door would not release upon activation of the fire alarm system.

Exit interview with the facility administrator, maintenance one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the smoke barrier separation door would not release upon activation of the building fire alarm system.

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, between 10:12 a.m. and 10:14 a.m. revealed the following hazardous area enclosure doors lacked self-closing devices.

a. 10:12 a.m., Unit 311 Storage Room.
b. 10:14 a.m., Housekeeping Storage (third floor.)

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the Unit 311 Storage Room and the Housekeeping Storage Room lacked self-closing devices.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures, affecting two of seventeen smoke compartments.

Findings include:

1. Observation on April 20, 2015, between 11:10 AM and 12:30 PM revealed the following rooms with doors lacking self-closing devices.

a. 11:10 AM - 3rd floor Mechanical room #331.

b. 12:28 PM - 2nd floor room #2332, being used for storage.

c. 12:29 PM - 2nd floor room #2333, being used for storage.

d. 12:30 PM - 2nd floor room #2334, being used for storage.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the lack of self-closing devices.

Based on observation and interview the facility failed to maintain exit stair towers in two instances within the component.

Findings include:

1. Observation on April 20, 2015, at 1:40 PM revealed the 1st floor stair tower #1114 had an IT closet located under the lower landing.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the IT closet within a stair tower.

2. Observation on April 21, 2015, at 8:10 AM revealed the Basement level stair tower door #1028 had storage at the bottom of the stairs.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the storage in the stair tower.

Based on observation and interview it was determined the facility failed to provide illumination to one exit discharge path at this component.

Findings include:

1. Observation on April 20, 2015, at 1:30 PM, revealed the 1st floor, East exit lacked adequate continuous lighting, due to a broken light fixture.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the area lacked continuous lighting.

Based on observation and interview, it was determined the facility failed to maintain illuminated exit signage in one of seventeen smoke compartments within the component.

Findings include:

1. Observation on April 20, 2015, at 1:20 PM revealed an illuminated exit sign located above the 1st floor Soiled Linen room door.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the improperly located exit sign.

Based on observation and interview, it was determined the facility failed to install and maintain automatic sprinkler protection in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 9:55 a.m. revealed the basement-level, 0007 Electrical Room lacked automatic sprinkler protection.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the 0007 Electrical Room lacked automatic sprinkler protection.

Based on observation and interview, it was determined the facility failed to install and maintain automatic sprinkler protection in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 10:16 AM revealed the 3rd floor wet area had perforated suspended ceilings with no sprinkler coverage above.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the non-sprinklered area.

2. Observation on April 21, 2015, at 9:30 AM revealed the basement level Electrical rooms did not have sprinkler coverage.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the non-sprinklered area.

Based on documentation review and interview, it was determined the facility failed to conduct quarterly sprinkler testing and inspection within the required time frame affecting four of four floors in this component.

Findings include:

1. Review of quarterly sprinkler testing and inspection documentation on April 20, 2015, at 9:15 AM, revealed the facility had over 150 days between the fourth quarter 2014 and first quarter 2015 inspections.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the quarterly sprinkler inspection and testing intervals were not conducted within the required time frame.

Based on documentation review and interview, it was determined the facility failed to conduct quarterly sprinkler testing and inspection within the required time frame affecting four of four floors in this component.

Findings include:

1. Review of quarterly sprinkler testing and inspection documentation on April 20, 2015, at 9:15 AM, revealed the facility had over 150 days between the fourth quarter 2014 and first quarter 2015 inspections.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the quarterly sprinkler inspection and testing intervals were not conducted within the required time frame .

2. Observation on April 20, 2015, at 10:16 AM revealed the 4th floor Wet Area had sprinkler piping disconnected from the system due to prior freezing.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM confirmed the disconnected piping.

Based on observation and interview, it was determined the facility failed to maintain one fire extinguisher affecting one of three floors in this component.

Findings include:

1. Observation on April 20, 2015, at 9:57 AM, revealed the first floor fire extinguisher cabinet marker light, near door 1036, was not illuminated.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the marker light for the fire extinguisher, near door 1036, was out.

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of five levels.

Findings include:

1. Observation on April 20, 2015, at 10:53 a.m. revealed multiple cigarette refuse littering the ground in the outdoor, female smoking area.

Exit interview with the facility administrator, maintenance representative one, and facility maintenance representative two on April 21, 2015, between 10:30 a.m. and 10:45 a.m. confirmed the smoking regulations deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting four of four floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on April 20, 2015, at 9:30 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator, maintenance representative #1 and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting four of four floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on April 20, 2015, at 9:30 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting three of three floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on April 20, 2015, at 9:30 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator, maintenance representative #1and facility maintenance representative #2 on April 21, 2015, between 10:30 AM and 10:45 AM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels for the past year.