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Based on observation and interview it was determined that the facility failed to ensure that common walls are properly inspected and maintain a fire resistive rating free of unsealed penetrations in two of four levels within this component.

Findings include:

Observations made on March 10, 2014 between 8:45am and 9:00am, revealed unsealed penetrations in the common walls at the following locations:

a. 8:45am, third floor at the Radill building separation common wall above the double doors, black wire penetration.
b. 9:00am, basement level Domestic water room, there was a penetration of the fire wall by two bundles of Armor cables that are above the two wall mounted electrical outlets that are next to the elevator shaft wall.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the penetrations of the common wall.

Based on observation and interview, it was determined the facility failed to ensure the corridors are separated from use areas by walls constructed with at least a 1/2 hour fire resistive rating for non sprinklered buildings in one of two smoke compartments.

Findings include:

Observations on March 10, 2014 between 11:15am and 11:40am, revealed unsealed penetrations of the corridor walls in the following locations:

a. 11:15am, above the door to electrical circuit breaker room P 132, unsealed penetration of phone wires.
b. 11:40am, above the double doors to the Rec hall/Auditorium, several unsealed wire penetrations of the corridor wall.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the unsealed penetrations of the corridor wall.

Based on observation and interview, it was determined the facility failed to ensure the corridors were separated from use areas by walls constructed with at least a 1/2 hour fire resistive rating for non-sprinklered buildings in one of 10 smoke compartments within this component.

Findings include:

Observation on March 10, 2014 at 10:10am, revealed on the second floor center wing at kitchen 242 and above the suspended ceiling the corridor wall had several unsealed penetrations. Also, an approximately four foot long layer of dry wall was missing from the corridor wall.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the condition of the corridor wall.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors positively latched into the door frame and remained closed in the frame on one of two levels within this component.

Findings include:

Observation on March 10, 2014 at 11:40am, revealed the corridor doors to the Rec Hall/Auditorium did not positively latch into the door frame. The doors were not equipped with positive latching devices.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the corridor doors failed to positively latch.

Based on observation and interview it was determined that the facility failed to ensure that corridor doors are properly inspected and maintained to positively latch resist the passage of smoke and free of impediments in seven of 10 smoke compartments within this component.

Findings include:

1. Observations made on march 10, 2014 between 8:50am and 9:41am, revealed the following corridor doors had gaps greater than one half inches between the door and the frame which would not resist the passage of smoke:

a. 8:50 am, third floor, resident room 303.
b. 9:41 am, the first floor South wing, the door to patient room #162.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00 pm, confirmed the condition of the doors

2. Observations made on March 10, 2014 between 9:00am, and 10:04am, revealed corridor doors that failed to positively latch when tested in the following locations:

a. 9:00am, third floor resident room 328.
b. 9:10am, third floor the upper leaf of the dutch doors located at room 365.
c. 9:43am, first floor South wing patient room # M 160.
d. 9:50am, second floor interview room M211A, did not have positive latching device.
d. 10:04am, first floor Center wing patient room # 140.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the doors failed to latch when tested in the above named locations.

3. Observations made on March 10, 2014 between 9:51am and 10:00am, revealed the following corridor doors were held open with unauthorized devices:

a. 9:51am, first floor South wing, the door to the isolation room that opens up to the nurse station was being held open by a rubber wedge.
b. 10:00 am, second floor resident room M241, door held open with rubber wedge.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the doors were wedged open and the subsequent correction of the deficiencie during the time of the survey.

Based on observation and interview it was determined that the facility failed to ensure that shaft walls are were properly inspected and maintain a fire resistive rating free of unsealed penetrations in one of four levels within this component.

Findings include:

Observation made on March 10, 2014 at 9:01am, revealed that on the basement level Domestic water room, there was a unsealed penetration of the elevator shaft wall by a Armor cable that is next to the two wall mounted electrical panels.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the penetration of the elevator shaft wall.

Based upon observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in two of 10 smoke compartments within this component.

Findings include:

Observation on March 10, 2014 at 9:10am, revealed on the third floor there were unsealed BX cable penetrations in the smoke barrier wall located by room 342.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain a one hour fire rated construction protecting hazardous areas that were not sprinklered and the facility failed to ensure the doors to hazardous areas were self closing on one of two levels within this component.

Findings include:

Observation on March 10, 2014 at 11:02am, revealed in the Recreation Hall room at the stage area, there was an office being utilized to store numerous cardboard items, paper, and paper products. The door to the room did not have a label indicating the fire resistive rating of the door construction and the door did not have a self closing device. The office was greater than 50 square feet in area.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the condition of the storage room door.

Based on observation and interview it was determined that the facility failed to ensure that hazardous storage rooms were properly inspected and maintained that doors were self closing in one of four levels within this component.

Findings include:

1. Observation made on march 10, 2014 at 9:12am, revealed that in the ground floor multi purpose room, the door to the storage room that is near the stage and the exit door to the exterior lacked a self closer. The door also was split at the middle where the locking hardware is. The room is greater than fifty square feet and contains mattresses, furniture and floor mats. The room is also non sprinklered.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the door lacks a closer and is damaged.

2. Observation made on March 10, 2014 at 10:21am, revealed that on the first floor Nursing Administration suite file storage room door lacks a self closer. The room is greater than fifty square feet and contains paper files in a open file shelf system.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the door to the file room lacked a self closer.

Based on observation and interview it was determined that the facility failed to ensure that the fire alarm system is properly inspected and maintained that pull stations are free of obstructions in one of four levels within this component.

Findings include:

Observation made on March 10, 2014 at 7:45am, revealed that ground floor front lobby area, the fire alarm pull station that is next to the sliding door was obstructed by a plant and a glove box.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the pull station was obstructed and the subsequent correction of the deficiency during the time of the survey.

Based on observation and interview it was determined that the facility failed to ensure that sprinkler system piping and stand pipes are free of external loads in one of four levels within this component.

Findings include:

Observation made on March 10, 2014 at 10:19am, revealed that on the first floor above the ceiling by the center stair tower, there were bundles of Armor cables and data wiring that were laying on the sprinkler/standpipe.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the external loads on the sprinkler system piping.

Based on observation, interview, and document review it was determined that the facility failed to ensure that fire and smoke dampers were properly inspected and maintained within this component.

Findings include:

Document review made on March 10, 2014 at 1:45pm, revealed the fire and smoke damper inspection report dated June 13, 2013 identified eight dampers had failed or were inaccessible at the time of the inspection. A follow up repair inspection report dated January 8, 2014, indicated that of the eight failed dampers there were still four dampers that had not been repaired as of March 10, 2014.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed all the dampers were not yet completely repaired.

Based on observation and interview it was determined the facility failed to ensure power strips were properly utilized one of two levels within this component.

Findings include:

Observation on March 10, 2014 at 11:00am, revealed in office room 125A, there were two daisy chained power strips providing power to office equipment.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the unauthorized use of power strips.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained that the improper and unauthorized use of powers trips and extension cords is prohibited, that electrical outlets and wiring is protected in five of 10 smoke compartments within this component.

Findings include:

1. Observations made on March 10, 2014 between 9:23am, and 11:11am, revealed the improper and unauthorized use of power strips and extension cords in the following locations:

a. 9:23am, basement level elevator machine room, yellow extension cord being used to power a switch on the elevator machinery that is mounted on the hydraulic tank assembly.
b. 9:25am, third floor south wing, inside the staff locker room, coffee maker and refrigerator powered by a surge protector.
c. 9:35am, first floor South wing # 1, office #168, power strip daisy chained into another power strip.
d. 10:09am, first floor Center Charting room, refrigerator being powered by a yellow extension cord.
e. 10:16am, first floor Center wing office #M 137 B, refrigerator plugged into a power strip.
f. 10:24am, first floor Nursing Administration office #134, refrigerator plugged into a power strip.
g. 10:37am, first floor Medical Administration suite office #12 C, refrigerator plugged into a power strip.
h. 10:40am, first floor Executive suite room #124 front desk, power strip daisy chained into a power strip.
i. 10:50am, first floor Admissions suite office #M 119 B, power strip daisy chained into a power strip.
j. 10:55am, first floor Admissions suite cubicle section, right side desk, two yellow extension cords in use to power computers and left side desk, home made quad outlet box extension cord that plugged into another extension cord.
k. 11:11am, first floor Admissions suite office right side rear office, refrigerator and microwave oven being powered by yellow extension cords.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the improper and unauthorized uses of power strips and extension cords in the above named locations.

2. Observation made on March 10, 2014 at 8:45am, revealed that on the basement level above the ceiling by the double fire doors to the Kitchen, there was a open junction box and a Armor cable with exposed inner wiring protruding from it.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the open junction box and Armor cable with exposed wiring.

3. Observation made on March 10, 2014 at 10:06am, revealed that on the first floor Center wing Nurse station below the desk, there was a electrical outlet that was loose from the drywall and was missing the face plate.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the loose outlet and missing face plate.

4. Observation made on March 10, 2014 at 10:27am, revealed that on the First floor Nursing office #139, there was a shelf assembly that was within three feet of a wall mounted electrical outlet. The shelf prevents the panel door from being fully opened.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the shelf was too close to the electrical panel.

Based on observation and interview it was determined that the facility failed to ensure that common walls are properly inspected and maintain a fire resistive rating free of unsealed penetrations in two of four levels within this component.

Findings include:

Observations made on March 10, 2014 between 8:45am and 9:00am, revealed unsealed penetrations in the common walls at the following locations:

a. 8:45am, third floor at the Radill building separation common wall above the double doors, black wire penetration.
b. 9:00am, basement level Domestic water room, there was a penetration of the fire wall by two bundles of Armor cables that are above the two wall mounted electrical outlets that are next to the elevator shaft wall.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the penetrations of the common wall.

Based on observation and interview, it was determined the facility failed to ensure the corridors are separated from use areas by walls constructed with at least a 1/2 hour fire resistive rating for non sprinklered buildings in one of two smoke compartments.

Findings include:

Observations on March 10, 2014 between 11:15am and 11:40am, revealed unsealed penetrations of the corridor walls in the following locations:

a. 11:15am, above the door to electrical circuit breaker room P 132, unsealed penetration of phone wires.
b. 11:40am, above the double doors to the Rec hall/Auditorium, several unsealed wire penetrations of the corridor wall.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the unsealed penetrations of the corridor wall.

Based on observation and interview, it was determined the facility failed to ensure the corridors were separated from use areas by walls constructed with at least a 1/2 hour fire resistive rating for non-sprinklered buildings in one of 10 smoke compartments within this component.

Findings include:

Observation on March 10, 2014 at 10:10am, revealed on the second floor center wing at kitchen 242 and above the suspended ceiling the corridor wall had several unsealed penetrations. Also, an approximately four foot long layer of dry wall was missing from the corridor wall.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the condition of the corridor wall.

Based on observation and interview, it was determined the facility failed to ensure the corridor doors positively latched into the door frame and remained closed in the frame on one of two levels within this component.

Findings include:

Observation on March 10, 2014 at 11:40am, revealed the corridor doors to the Rec Hall/Auditorium did not positively latch into the door frame. The doors were not equipped with positive latching devices.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the corridor doors failed to positively latch.

Based on observation and interview it was determined that the facility failed to ensure that corridor doors are properly inspected and maintained to positively latch resist the passage of smoke and free of impediments in seven of 10 smoke compartments within this component.

Findings include:

1. Observations made on march 10, 2014 between 8:50am and 9:41am, revealed the following corridor doors had gaps greater than one half inches between the door and the frame which would not resist the passage of smoke:

a. 8:50 am, third floor, resident room 303.
b. 9:41 am, the first floor South wing, the door to patient room #162.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00 pm, confirmed the condition of the doors

2. Observations made on March 10, 2014 between 9:00am, and 10:04am, revealed corridor doors that failed to positively latch when tested in the following locations:

a. 9:00am, third floor resident room 328.
b. 9:10am, third floor the upper leaf of the dutch doors located at room 365.
c. 9:43am, first floor South wing patient room # M 160.
d. 9:50am, second floor interview room M211A, did not have positive latching device.
d. 10:04am, first floor Center wing patient room # 140.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the doors failed to latch when tested in the above named locations.

3. Observations made on March 10, 2014 between 9:51am and 10:00am, revealed the following corridor doors were held open with unauthorized devices:

a. 9:51am, first floor South wing, the door to the isolation room that opens up to the nurse station was being held open by a rubber wedge.
b. 10:00 am, second floor resident room M241, door held open with rubber wedge.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the doors were wedged open and the subsequent correction of the deficiencie during the time of the survey.

Based on observation and interview it was determined that the facility failed to ensure that shaft walls are were properly inspected and maintain a fire resistive rating free of unsealed penetrations in one of four levels within this component.

Findings include:

Observation made on March 10, 2014 at 9:01am, revealed that on the basement level Domestic water room, there was a unsealed penetration of the elevator shaft wall by a Armor cable that is next to the two wall mounted electrical panels.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the penetration of the elevator shaft wall.

Based upon observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in two of 10 smoke compartments within this component.

Findings include:

Observation on March 10, 2014 at 9:10am, revealed on the third floor there were unsealed BX cable penetrations in the smoke barrier wall located by room 342.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain a one hour fire rated construction protecting hazardous areas that were not sprinklered and the facility failed to ensure the doors to hazardous areas were self closing on one of two levels within this component.

Findings include:

Observation on March 10, 2014 at 11:02am, revealed in the Recreation Hall room at the stage area, there was an office being utilized to store numerous cardboard items, paper, and paper products. The door to the room did not have a label indicating the fire resistive rating of the door construction and the door did not have a self closing device. The office was greater than 50 square feet in area.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the condition of the storage room door.

Based on observation and interview it was determined that the facility failed to ensure that hazardous storage rooms were properly inspected and maintained that doors were self closing in one of four levels within this component.

Findings include:

1. Observation made on march 10, 2014 at 9:12am, revealed that in the ground floor multi purpose room, the door to the storage room that is near the stage and the exit door to the exterior lacked a self closer. The door also was split at the middle where the locking hardware is. The room is greater than fifty square feet and contains mattresses, furniture and floor mats. The room is also non sprinklered.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the door lacks a closer and is damaged.

2. Observation made on March 10, 2014 at 10:21am, revealed that on the first floor Nursing Administration suite file storage room door lacks a self closer. The room is greater than fifty square feet and contains paper files in a open file shelf system.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the door to the file room lacked a self closer.

Based on observation and interview it was determined that the facility failed to ensure that the fire alarm system is properly inspected and maintained that pull stations are free of obstructions in one of four levels within this component.

Findings include:

Observation made on March 10, 2014 at 7:45am, revealed that ground floor front lobby area, the fire alarm pull station that is next to the sliding door was obstructed by a plant and a glove box.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the pull station was obstructed and the subsequent correction of the deficiency during the time of the survey.

Based on observation and interview it was determined that the facility failed to ensure that sprinkler system piping and stand pipes are free of external loads in one of four levels within this component.

Findings include:

Observation made on March 10, 2014 at 10:19am, revealed that on the first floor above the ceiling by the center stair tower, there were bundles of Armor cables and data wiring that were laying on the sprinkler/standpipe.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the external loads on the sprinkler system piping.

Based on observation, interview, and document review it was determined that the facility failed to ensure that fire and smoke dampers were properly inspected and maintained within this component.

Findings include:

Document review made on March 10, 2014 at 1:45pm, revealed the fire and smoke damper inspection report dated June 13, 2013 identified eight dampers had failed or were inaccessible at the time of the inspection. A follow up repair inspection report dated January 8, 2014, indicated that of the eight failed dampers there were still four dampers that had not been repaired as of March 10, 2014.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed all the dampers were not yet completely repaired.

Based on observation and interview it was determined the facility failed to ensure power strips were properly utilized one of two levels within this component.

Findings include:

Observation on March 10, 2014 at 11:00am, revealed in office room 125A, there were two daisy chained power strips providing power to office equipment.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the unauthorized use of power strips.

Based on observation and interview it was determined that the facility failed to ensure that electrical wiring and equipment is properly inspected and maintained that the improper and unauthorized use of powers trips and extension cords is prohibited, that electrical outlets and wiring is protected in five of 10 smoke compartments within this component.

Findings include:

1. Observations made on March 10, 2014 between 9:23am, and 11:11am, revealed the improper and unauthorized use of power strips and extension cords in the following locations:

a. 9:23am, basement level elevator machine room, yellow extension cord being used to power a switch on the elevator machinery that is mounted on the hydraulic tank assembly.
b. 9:25am, third floor south wing, inside the staff locker room, coffee maker and refrigerator powered by a surge protector.
c. 9:35am, first floor South wing # 1, office #168, power strip daisy chained into another power strip.
d. 10:09am, first floor Center Charting room, refrigerator being powered by a yellow extension cord.
e. 10:16am, first floor Center wing office #M 137 B, refrigerator plugged into a power strip.
f. 10:24am, first floor Nursing Administration office #134, refrigerator plugged into a power strip.
g. 10:37am, first floor Medical Administration suite office #12 C, refrigerator plugged into a power strip.
h. 10:40am, first floor Executive suite room #124 front desk, power strip daisy chained into a power strip.
i. 10:50am, first floor Admissions suite office #M 119 B, power strip daisy chained into a power strip.
j. 10:55am, first floor Admissions suite cubicle section, right side desk, two yellow extension cords in use to power computers and left side desk, home made quad outlet box extension cord that plugged into another extension cord.
k. 11:11am, first floor Admissions suite office right side rear office, refrigerator and microwave oven being powered by yellow extension cords.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the improper and unauthorized uses of power strips and extension cords in the above named locations.

2. Observation made on March 10, 2014 at 8:45am, revealed that on the basement level above the ceiling by the double fire doors to the Kitchen, there was a open junction box and a Armor cable with exposed inner wiring protruding from it.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the open junction box and Armor cable with exposed wiring.

3. Observation made on March 10, 2014 at 10:06am, revealed that on the first floor Center wing Nurse station below the desk, there was a electrical outlet that was loose from the drywall and was missing the face plate.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the loose outlet and missing face plate.

4. Observation made on March 10, 2014 at 10:27am, revealed that on the First floor Nursing office #139, there was a shelf assembly that was within three feet of a wall mounted electrical outlet. The shelf prevents the panel door from being fully opened.

Interview at the exit conference with the Director of Facilities Management and Supervisor Plant Operations on March 10, 2014 at 2:00pm, confirmed the shelf was too close to the electrical panel.