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The facility failed to ensure a complete two-hour fire resistive rated wall assembly between the hospital and the clinic.

Observation determined the 90-minute fire rated double door between the Kitchen Service Corridor and the Clinic was not equipped with an astragal that would close the gap between the door leaves.

The facility failed to ensure the corridor doors resisted the passage of smoke.

Observation determined the door to the Dictation Office (old Tub Room) was equipped with a louver and was not smoke resistive.

Whenever devices are added to or alterations are made to a fire alarm system, all initiating devices and signaling devices must be tested to ensure the fire alarm panel recognizes and addresses each device.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test records indicated:

1) The facility failed to ensure the fire alarm system was operating properly. The June 2011 fire alarm test report indicated that three devices failed the test but were not replaced.

2) The final test results of the newly installed fire alarm devices were not available for review.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

1) Observation determined:

a) The two sprinklers in the X-ray Storage Room were obstructed by surface mounted light fixtures.

b) One of the sprinklers in the Tub Room was obstructed by a privacy curtain.

2) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system. Observation determined three suspended ceiling tiles were missing in Data/IT Room.

3) Sprinkler record review could not verify the newly installed sprinkler system was tested for compliance with NFPA 25.

Electrical wiring throughout a health care occupancy must comply with NFPA 70, National Electrical Code.

The facility failed to ensure electrical wiring and electrical equipment comply with NFPA 70.

Observation determined the Whirl Pool Tub was not Ground Fault Circuit Interrupter (GFCI) protected.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

1) Observation determined:

a) The two sprinklers in the X-ray Storage Room were obstructed by surface mounted light fixtures.

b) One of the sprinklers in the Tub Room was obstructed by a privacy curtain.

2) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system. Observation determined three suspended ceiling tiles were missing in Data/IT Room.

3) Sprinkler record review could not verify the newly installed sprinkler system was tested for compliance with NFPA 25.