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Based on observations and interviews, the facility failed to maintain the proper operation of corridor doors assemblies to properly self-close and latch upon release to maintain the fire resistance rated barrier penetration. Failure to maintain the corridor door assembly will allow for the travel of fire and smoke gases from one compartment to another endangering patients, staff, or other building occupants.

The findings include:

1) While on tour with the Facilities Operations Manager on January 26, 2015, the entry doors to the rooms at the following location were observed to be out of alignment and would not come to a fully closed and latch position upon release.
a. 11:56 AM - children ward/observation room,
b. 12:15 PM on Crisis Stabilization Unit (CSU) ward/adult day room, at 12:22 PM on CSU ward/room 13,
c. 12:30 PM on CSU ward/janitor closet

The Facilities Operations Manager confirmed during these observations that the doors would not fully close and latch. NFPA 101 (2000) chapter 19.3.6.3 requires corridor doors to resist the passage of smoke and latch upon release.

2) While on tour January 26, 2015 at 12:10 PM on CSU ward/social services area, with the Facilities Operations Manager, the corridor doors to the rooms were observed to be held open with plastic wedges and book shelf. The Facilities Operations Manager confirmed the doors was held open and would not fully close and latch. NFPA 101 (2000) chapter 19.3.6.3 requires that there shall be no impediment to the closing of the doors.

Based on observation and interview, the facility failed to maintain their egress signs. The enclosed courtyard area egress doors are missing egress signage. Residents, visitors and staff would lack egress direction during an emergency.

The findings include:

While on tour on January 26, 2015 at 11:45 AM in the enclosed courtyard area with the Facilities Operations Manager, it was observed that three courtyard exit doors are missing egress signage. The Facilities Operations Manager confirmed the missing signage. NFPA 101 (2000 edition) chapter 19.2.10; chapter 7.10.8 requires any door or passage that is not an exit or exit passage to be identified.

Based on observation, the facility failed to properly test and maintain their fire sprinkler system. The inspector's test connection, which tests the fire sprinkler water flow switch , does not house an orifice. The inspector's test simulates the activation of the smallest sprinkler in the system and must house an orifice the size of the orifice in the smallest sprinkler.

The findings include:

While on tour January 26, 2015 at 12:45 PM of the outside/ exterior wall drain with the Facilities Operations Manager, the inspecto'rs test connection was observed with no orifice. The Facilities Operations Manager confirmed that the orifice was not installed. NFPA 25 (1998 edition) chapter 8.17.4. requires an orifice equal to or less than the smallest sprinkler orifice.

Based on observation, the facility failed to properly maintain their heating, air-conditioning and ventilating (HVAC) system. The bath exhaust in the resident's rooms in the crisis stabilization ward are not operating.

The findings include:

While on tour January 26, 2015 at 12:18 PM on crisis stabilization ward/room #11 with the Facilities Operations Manager, the exhaust grilles failed to retain a sheet of toilet tissue when held to the grille in the residents bathrooms. NFPA 101(2000 edition) chapter 19.5.2; chapter 9.2.1 requires HVAC be maintained and installed in accordance with the manufacturer's specifications.