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Based on observation, record review, and interview, the facility failed to maintain their horizontal WON fire door. This was evidenced by no records of annually testing the door. This affected one of two smoke compartments and could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.14 Horizontal Sliding Doors. Horizontal sliding doors shall be permitted in means of egress, provided that the following criteria are met:
(1) The door is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf (67 N).
(3) The force required to operate the door in the direction of door travel is not more than 30 lbf (133 N) to set the door in motion and is not more than 15 lbf (67 N) to close the door or open it to the minimum required width.
(4) The door is operable with a force not more than 50 lbf
(222 N) when a force of 250 lbf (1110 N) is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of
fewer than 50.
(5) The door assembly complies with the fire protection rating and, where rated, is self-closing or automatic-closing by means of smoke detection in accordance with 7.2.1.8, and is installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2-4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written records shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During record review with staff on 8/3/16, records of testing the horizontal sliding WON door in administration was requested. The door ran across approximately 10 feet of the egress corridor in administration and was connected to two smoke detectors.

1. At 11:52 a.m., a quote dated 6/22/16 for testing the WON door was provided. The quote was signed by Facilities Staff 1 on 7/13/16. There were no records of the testing provided.

During an interview at 11:53 a.m., Facilities Staff 1 stated that the testing date has not yet been scheduled.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by deficiencies noted during an annual inspection in November that were not yet repaired. This was also evidenced by an Inspector's Test Valve (ITV) that failed to activate the fire alarm system within 90 seconds. This affected the entire building including two of two smoke compartments of the psychiatric health facility (PHF). This could result in a delay in extinguishing a fire and a delay in notification of a sprinkler activation.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.
Exception: Where an occupant, management firm, or managing individual has received the authority for inspection, testing, and maintenance in accordance with the Exception to 1-4.2, the occupant, management firm, or managing individual shall comply with 1-4.4.

2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 72, National Fire Alarm Code, 2000 Edition.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a facility tour with staff on 8/3/16, the sprinkler system was observed and the maintenance records were reviewed.

1. At 12:13 p.m., records showed that an annual inspection of the sprinkler system was conducted by a licensed vendor on 11/23/15. The vendor noted, "there are a couple of spots where water is leaking from the floor above piping and it is rusting the pipe heavily. This needs to be repaired before the system is tagged complete. A quote will be provided upon request."

A quote dated 1/13/16 was provided but there were no records showing that the repairs were complete.

At 1:40 p.m., a sprinkler pipe in the sprinkler riser room directly below the PHF was heavily corroded in two different spots. Approximately 12 inches of the pipe was heavily corroded in one area and approximately 8 inches of the pipe was heavily corroded in the other area. The approximately 8-inch corroded part of the pipe also had an unknown protruding white-colored substance in the middle of the corroded area. There were water stains in the concrete ceiling directly above these corroded sections of the pipe.

During an interview at 1:41 p.m., General Services Staff 2 stated that the corroded areas were directly below two bathrooms in the PHF. He stated that the bathrooms in the PHF were leaking for a long time and the leaks were only recently repaired in June 2016. He acknowledged that the sprinkler pipes were heavily corroded.

2. At 12:15 p.m., records showed that the ITV consistently alarmed within 90 seconds during inspections until May 2016. Per the documents provided, the ITV alarmed in 30 seconds on 9/30/16 and 2/14/16 when tested by General Services Staff 2 and it alarmed in 28 seconds when tested by the vendor on 11/23/15. Testing records from 5/26/16 showed that the ITV alarmed in 95 seconds when tested by General Services Staff 2.

During an interview at 1:23 p.m., General Services Staff 2 stated that the flow switch on the ITV has not yet been fixed to alarm within 90 seconds. He stated that he reported the failure to the General Services Department. He also said that there is a leak in the check valve in the riser that may also be causing the delay in alarm activation.

At 2:33 p.m., the ITV was tested in the presence of Plumber 1, Facilities Staff 1, and General Services Staff 2. The ITV activated the fire alarm system after 109 seconds, 19 seconds past the maximum allowed time of 90 seconds.

During an interview at 2:34 p.m., Plumber 1 stated that there was a leaking check valve in the riser which would be difficult to repair because of obsolete parts.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by one exit corridor that was obstructed. This affected one of two smoke compartments and could result in a delay in staff response and egress, in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff on 8/3/16, the egress paths were observed.

1. At 2:20 p.m., the cross-corridor exit door adjacent to Room 1 led to the exit corridor in the administration. There was a large copier in the administrative exit corridor and there were two recycling receptacles on the other side of the corridor. Egress was obstructed from 8 feet to approximately 4 feet of clear width.

During an interview at 2:21 p.m., Facilities Staff 1 stated that the copier was placed there a few months ago.

Based on observation, record review, and interview, the facility failed to maintain their horizontal WON fire door. This was evidenced by no records of annually testing the door. This affected one of two smoke compartments and could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.14 Horizontal Sliding Doors. Horizontal sliding doors shall be permitted in means of egress, provided that the following criteria are met:
(1) The door is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf (67 N).
(3) The force required to operate the door in the direction of door travel is not more than 30 lbf (133 N) to set the door in motion and is not more than 15 lbf (67 N) to close the door or open it to the minimum required width.
(4) The door is operable with a force not more than 50 lbf
(222 N) when a force of 250 lbf (1110 N) is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of
fewer than 50.
(5) The door assembly complies with the fire protection rating and, where rated, is self-closing or automatic-closing by means of smoke detection in accordance with 7.2.1.8, and is installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2-4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written records shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During record review with staff on 8/3/16, records of testing the horizontal sliding WON door in administration was requested. The door ran across approximately 10 feet of the egress corridor in administration and was connected to two smoke detectors.

1. At 11:52 a.m., a quote dated 6/22/16 for testing the WON door was provided. The quote was signed by Facilities Staff 1 on 7/13/16. There were no records of the testing provided.

During an interview at 11:53 a.m., Facilities Staff 1 stated that the testing date has not yet been scheduled.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by deficiencies noted during an annual inspection in November that were not yet repaired. This was also evidenced by an Inspector's Test Valve (ITV) that failed to activate the fire alarm system within 90 seconds. This affected the entire building including two of two smoke compartments of the psychiatric health facility (PHF). This could result in a delay in extinguishing a fire and a delay in notification of a sprinkler activation.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.
Exception: Where an occupant, management firm, or managing individual has received the authority for inspection, testing, and maintenance in accordance with the Exception to 1-4.2, the occupant, management firm, or managing individual shall comply with 1-4.4.

2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 72, National Fire Alarm Code, 2000 Edition.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a facility tour with staff on 8/3/16, the sprinkler system was observed and the maintenance records were reviewed.

1. At 12:13 p.m., records showed that an annual inspection of the sprinkler system was conducted by a licensed vendor on 11/23/15. The vendor noted, "there are a couple of spots where water is leaking from the floor above piping and it is rusting the pipe heavily. This needs to be repaired before the system is tagged complete. A quote will be provided upon request."

A quote dated 1/13/16 was provided but there were no records showing that the repairs were complete.

At 1:40 p.m., a sprinkler pipe in the sprinkler riser room directly below the PHF was heavily corroded in two different spots. Approximately 12 inches of the pipe was heavily corroded in one area and approximately 8 inches of the pipe was heavily corroded in the other area. The approximately 8-inch corroded part of the pipe also had an unknown protruding white-colored substance in the middle of the corroded area. There were water stains in the concrete ceiling directly above these corroded sections of the pipe.

During an interview at 1:41 p.m., General Services Staff 2 stated that the corroded areas were directly below two bathrooms in the PHF. He stated that the bathrooms in the PHF were leaking for a long time and the leaks were only recently repaired in June 2016. He acknowledged that the sprinkler pipes were heavily corroded.

2. At 12:15 p.m., records showed that the ITV consistently alarmed within 90 seconds during inspections until May 2016. Per the documents provided, the ITV alarmed in 30 seconds on 9/30/16 and 2/14/16 when tested by General Services Staff 2 and it alarmed in 28 seconds when tested by the vendor on 11/23/15. Testing records from 5/26/16 showed that the ITV alarmed in 95 seconds when tested by General Services Staff 2.

During an interview at 1:23 p.m., General Services Staff 2 stated that the flow switch on the ITV has not yet been fixed to alarm within 90 seconds. He stated that he reported the failure to the General Services Department. He also said that there is a leak in the check valve in the riser that may also be causing the delay in alarm activation.

At 2:33 p.m., the ITV was tested in the presence of Plumber 1, Facilities Staff 1, and General Services Staff 2. The ITV activated the fire alarm system after 109 seconds, 19 seconds past the maximum allowed time of 90 seconds.

During an interview at 2:34 p.m., Plumber 1 stated that there was a leaking check valve in the riser which would be difficult to repair because of obsolete parts.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by one exit corridor that was obstructed. This affected one of two smoke compartments and could result in a delay in staff response and egress, in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff on 8/3/16, the egress paths were observed.

1. At 2:20 p.m., the cross-corridor exit door adjacent to Room 1 led to the exit corridor in the administration. There was a large copier in the administrative exit corridor and there were two recycling receptacles on the other side of the corridor. Egress was obstructed from 8 feet to approximately 4 feet of clear width.

During an interview at 2:21 p.m., Facilities Staff 1 stated that the copier was placed there a few months ago.