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Based on observation and interview, it was determined the facility failed to maintain stair tower enclosures in three locations, affecting two of two floors.

Findings include:

1. Observation on May 9, 2023, between 11:12 a.m., and 11:53 a.m., revealed the following:

a. 11:12 a.m., the first floor, north core stair tower door enclosure lacked a fire-rated vision panel.
b. 11:14 a.m., non-rated, foam insulating materials within the basement-level, north core, stair tower wall enclosure.
c. 11:53 a.m., the south west, one, stair tower door was not fire-tight.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the stair tower enclosure deficiencies.

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

Findings include:

1. Observation on May 9, 2023, at 12:20 p.m., revealed the facility lacked ninety-minute bleed (or drain) testing of the battery-operated lighting fixture, located within the transfer switch room.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the emergency lighting deficiency.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting one of two floors

Findings include:

1. Observation on May 9, 2023, between 10:07 a.m., and 12:12 p.m., revealed the following:

a. 10:07 a.m., storage items were located within eighteen inches of a sprinkler head, within the first floor, Core Storage Room.
b. 12:12 p.m., a missing escutcheon plate located within the first floor, south west, Electrical Room.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor openings, affecting one of two floors.

Findings include:

1. Observation on May 9, 2023, at 10:23 a.m., revealed in excess of one-eighth-inch between the lower level, north, Copier Room doors.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation doors, affecting two of two floors.

Findings include:

1. Observation on May 9, 2023, between 10:47 a.m., and 12:14 p.m., revealed the following:

a. 10:47 a.m., the lower level, north, smoke barrier separation doors required adjustment to fully latch.
b. 12:14 p.m., the first floor, SR 221 smoke barrier separation door was damaged.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the smoke barrier separation door deficiencies.

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

Findings include:

1. Observation on May 9, 2023, revealed the faciltiy lacked three year, four hour, generator set, load testing data.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the generator set deficiency.

Based on observation and interview, it was determined the facility failed to maintain the electrical system in one location, affecting one of two floors.

Findings include:

1. Observation on May 9, 2023, at 10:16 a.m., revealed items were located within thirty-six inches of electrical panels, located within the first floor, Core Storage Room.

Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the electrical systems deficiency.