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Based on observation and interview with staff, the facility failed to provide doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure that are held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the fire alarm system.
Findings:

(1) The stair well door located in administration was blocked open with a plastic yellow wedge.
(2) Plastic yellow wedges were found in all areas of the hospital.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.
Findings:

(1) The smoke barriers have multiple penetrations at all zones.
(2) The spray foam used to repair some penetrations is for residential use only and does not meet the minimum requirements for a half hour fire barrier.

Based on observation and interview with staff, the facility failed to provide a fire alarm system that is installed and tested in accordance with NFPA 70 National Electrical Code and NFPA 72.
Findings:

(1) The repair completed on 3-15-11 was not documented with a 4 page receptacle test in accordance with NFPA 72. The code requires after any repair, modification, addition, deletion, or reprogramming that a reacceptance test be completed with documentation depicting the devices tested
(2) The Fire alarm annual test failed to document all equipment connected to the fire alarm system.
(3) The smoke detectors L2 S05, L2 S04, L2 S03 were 1 foot from the Air Diffuser. The code requires a minimum of 3 feet from the diffuser.

Based on observation and interview with staff, the facility failed to provide an Essential Electrical System in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.
Finding:

The transfer switches located adjacent to the 600 KW Generator outside and transfer switches located in the electrical rooms were not provided with 90 minute battery backup lighting.

Based on observation and interview with staff, the facility failed to provide generators that are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99.
Finding:

The Generator Logs failed to identify who conducted the weekly and monthly test.