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Based on observation and interview with staff, the facility failed to ensure that Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings include;

On April 23, 2013 at 2:30 PM with the Director of Maintenance the Smoke Barriers that separate the zones of the hospital were found to have small voids at the top of wall were CMU Block Wall meets the deck above were not filled with material capable of maintaining the fire resistance of the fire wall.

Small voids around Pipes, conduit and voids around duct work through the facility were not sealed with material capable of maintaining the fire resistance of the fire wall.

Based on observation and interview with staff, the facility failed to protect hazardous areas with One hour fire rated construction (with ¾ hour fire-rated doors) with 8.4.1 and/or 19.3.5.4 protects hazardous areas. Doors shall be provided with self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:

The door to the Chlorine storage room was eaten up with a oxidizing agent (chlorine) that prevented the door from closing tightly in its frame. The single layer sheet rock ceiling has voids that are not sealed. Chlorine shall be placed and stored off of the floor and in a manner that allows for access to the room.

The Maintenance shop located in room 333 was also used as a room to store combustibles. A 5 gallon container of combustible cleaning agent was stage in the room. The room was not equipment with a combustible storage cabinet.

Based on observation and interview with staff, the facility failed to tested, and maintain the fire alarm in accordance with NFPA 70 National Electrical Code and NFPA 72. The system is required to have a approved maintenance and testing program that compiles with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The Combination Fire and Smoke Dampers installed through out the hospital have not been inspected or tested for opening and closing. This is required during the annual test of the Fire Alarm. All components of the Fire Alarm are required to be tested annually.

The annual Fire Alarm Test conducted on October 4, 2012 required the Batteries to be changed out (batteries were installed 2005). At the time of the survey batteries have not been changed.

The annual inspection have not been signed.

Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

On April 23, 2013 at 3 PM with the CEO and Director of Maintenance the duct work that connects the powered exhaust from the swimming pools chlorine storage area was found deteriorated from chemical exposure.