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Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of common walls in three locations, affecting two of nine smoke compartments.

Findings include:

1. Observation on April 1, 2014, between 11:33 a.m. and 12:20 p.m. revealed the below common wall deficiencies:

a. 11:33 a.m., the mechanical room common wall door and door frame assemblies lacked labels.
b. 11:35 a.m., unsealed pipe penetrations within the mechanical room.
c. 12:20 p.m., second floor common wall doors between A and D buildings did not fully close when released.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the common wall deficiencies.

Based on observation and interview, it was determined the facility failed to construct and maintain vertical openings in two locations, affecting two of nine smoke compartments.

Findings include:

1. Observation on April 1, 2014, between 10:22 a.m. and 11:45 a.m. revealed unprotected horizontal structural steel located within the elevator enclosure at the first and second floors (structural steel integral to shaft construction).

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the unprotected structural steel within the elevator enclosure and identified that the facility has an acceptable FSES addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower in two locations, affecting two of nine smoke compartments.

Findings include:

1. Observation on April 1, 2014, between 10:33 a.m. and 10:36 a.m. revealed the below deficiencies of the east stair tower:

a. 10:33 a.m., the first floor stair tower door did not close when released from the magnetic hold-open device.
b. 10:36 a.m., unprotected structural steel within the first floor stair tower wall, within the adjacent conference room.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the stair tower enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower, affecting four of seven smoke compartments.

Findings include:

1. Observation on April 2, 2014, at 9:12 a.m. revealed two floor buffers charging within the number seven stair tower protected passageway.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the storage in the exit passageway.

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting fixtures, affecting two of two floors.

Findings include:

1. Observation on April 1, 2014, between 1:06 p.m. and 1:12 p.m. revealed the facility lacked the required annual 90 minute drain testing of battery-operated lighting fixtures throughout the facility.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the battery-operated lighting was not tested annually for 90 minutes.

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting two of nine smoke compartments.

Findings include:

1. Observation on April 1, 2014, at 12:40 p.m. revealed discarded cigarette butts located within the trash can, outside the northeast stair tower.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the cigarette butts were mixed with combustible trash.

Based on observation and interview, it was determined the facility failed to install and maintain heating, ventilation, and air conditioning systems in one location, affecting one of five smoke compartments.

Findings include:

1. Observation on April 2, 2014, at 8:12 a.m. revealed exhaust duct work within the elevator machine room lacked a fire damper, access panel, and retaining angles where exiting the shaft enclosure.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the duct lacked a fire damper, access panel, and retaining angles.

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one location, affecting one of seven smoke compartments.

Findings include:

1. Observation on April 2, 2014, at 9:29 a.m. revealed medical gas piping within Resident Room 401 was labeled incorrectly with respect to color.

Exit interview with the Facilities Manager on April 02, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the incorrect medical gas labeling.

Based on documentation review and interview, it was determined the facility failed to maintain battery operated task lighting for the emergency generator, affecting two of two floors.

Findings include:

1. Observation on April 1, 2014, between 1:06 p.m. and 1:12 p.m. revealed the facility lacked the required annual 90 minute drain testing of battery-operated task lighting fixtures within the generator set room.

Exit interview with the Facilities Manager on April 2, 2014, between 10:45 a.m. and 10:55 a.m. confirmed the battery-operated lighting was not tested annually for 90 minutes.