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Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls and ceilings constructed to limit the transfer of smoke. Findings:

1) Ceiling tiles throughout the facility are broken, cracked, warped, or are water damaged, thus are not constructed to limit the transfer of smoke.

2) The gypsum board ceiling in the Sterilizer Room has holes in the ceiling and openings around pipe penetrations in the ceiling.

Based on observation and interview with staff, the facility failed to provide corridor doors with a means suitable for keeping the door closed. Findings:

1) Roller latches are present on the patient room doors. Roller latches are prohibited by CMS regulations in all health care facilities.

2) The emergency exam room door (from corridor to exam room) does not have latching hardware. Section 19.3.6.3.2 reads "doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction." The closer that is installed on the door does not meet this requirement.

Based on observation with staff, the facility failed to provide at least two smoke compartments with smoke barriers having at least one half hour fire resistance rating. NFPA 101, Section 19.3.7.3 states that "any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one half hour." Findings:

1) Flammable expanding foam was found around penetrations and voids in the smoke barrier (smoke compartment wall) in violation of Section 19.3.7.3.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system installed in accordance with NFPA 13. Findings:

1) There are missing escutcheons on several sprinkler heads in the facility. Escutcheons shall be part of a listed sprinkler assembly per NFPA 13, Section 3-2.7.2.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, Chapter 4. Findings:

1) NFPA 99, Section 4-3.1.2.3(d) Zone Valve reads "station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet." The zone valve serving the emergency exam room is located within the served area, without intervening walls.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical system powered by a generator in accordance with NFPA 99. Findings:

1) NFPA 99, Section 3-4.1.1.15 Alarm Annunciator reads "a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station." The annunciator shall indicate alarm conditions of the emergency generator. There is not remote annunciator located at a regular work station in the facility.

Based on observation and interview with staff, the facility failed to provide master alarm panels in two separate locations having audible and visible signals. Findings:

1) NFPA 99, Section 4-3.1.2.2(b) Master Alarms reads "a master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems. The master alarm system shall consist of two ore more panels located in two separate locations." There are no master alarm panels for the medical gas system in the facility.