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Based upon observation, sprinkler systems are not maintained in accordance with Code requirements. Failure to maintain the sprinkler system can compromise occupant safety and building protection when the sprinkler system does not perform as intended to control a fire condition.

Findings include:

A. On 10/12/2021 at 9:10am while accompanied by the LHT it was observed that sprinkler heads were not in compliance with NFPA 13-2010, 8.5.5.3.1 regarding a fixed obstruction of four feet or greater. Location observed Level 1 Electrical room #E1017 area below duct.

B On 10/12/2021 at 9:12am while accompanied by the LHT it was observed that sprinkler heads were oriented not in compliance with NFPA 13-2010, 8.6.4.1 exceeding the maximum distance allowed from the deck above. Location observed Level 1 Electrical room #E1017.

C. On 10/12/2021 while accompanied by the LHT it was observed that a vertical change in ceiling elevation (ceiling pockets) is not in compliance with NFPA 13-2010 8.6.4.1.1.3, regarding sprinkler protection.
Locations observed:

1. At 10:12am Level 1 West Stair area to roof hatch
2. At 11:10am Maintenance area to roof hatch

D. On 10/12/2021 at 10:10am while accompanied by the LHT it was observed that sprinkler heads were not in compliance with NFPA 13-2010, 8.5.5.3.1 regarding a fixed obstruction of four feet or greater. Due to a stair run providing an obstruction, complete sprinkler protection at the level of exit discharge is not provided. Location observed Level 1 West Stair at level of exit discharge.

Based on observation, not all corridor doors are installed and maintained as required. Failure to maintain corridor doors in accordance with Code requirements could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor if the doors are not properly installed and maintained.

The finding is:

On 10/12/2021 at 9:30am while in the company of the LHT, it was observed that the Chapel corridor door was an aluminum store front which is smoke tight, however, it did not latch to comply with 19.3.6.3.5. Location observed: Level 2.

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

On 10/12/2021 at 11:45am while in the company of the LHT, documentation for fire rated doors was reviewed. The following information was not available:
There is no indication a complete fire door inspection was conducted to comply with any requirement of 7.2.1.15. For example:

1. There is no signed copy of inspections to comply with 7.2.1.15.4

2. There is no indication that the individuals who conduct the inspection comply with 7.2.1.15.5 for qualifications.

3. There is no indication that any doors requiring repair or modification have recieved them to comply with NFPA 80 2010, 5.1.5.1 for an immediate resolution.

4. There is no indication that any door has been inspected from both sides of the door to comply with 7.2.1.15.6.

5. There is no indication that any door has been inspected for the minimum items to comply with 7.2.1.15.7 (1)-(11).