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Based on observation and interview with staff, the facility failed to provide all exits marked by approved, readily visible signs. Findings:

1) Exit signs were not found at the exterior exits of each of the two patient room wings.

2) Exit signs were not found at each of the patient room wings leading toward the Nurse Station.

Based on observation and interview with staff, the facility failed to provide a smoke barrier of at least one-hour fire rating in accordance with Section 8.3. Findings:

1) An open gap exists in the smoke barrier between the top of the gypsum board and the bottom of the floor deck above.

2) Flammable expanding foam was found around penetrations and voids in the smoke barrier.

3) Open penetrations were found in the smoke barrier.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1, which requires a one-hour rating. Findings:

1) An open gap exists in the wall around hazardous areas between the top of the gypsum board and the bottom of the floor deck above.

2) Flammable expanding foam was found around penetrations and voids in the smoke barrier.

3) Open penetrations were found in the smoke barrier.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 18.5.2.1 and 9.2. Findings:

1) The exhaust fan in a patient room toilet was not operational.

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

1) The main medical gas shut off valves are unlocked and are located in an unrestricted corridor. Shut off valves shall be located to permit access by authorized personnel only (by locating in a ceiling or behind a locked access door) per 4-3.1.2.3 (b).

Based on observation and interview with staff, the facility failed to provide a Type I EES in accordance with NFPA 99, Section 3.4.2.2.2. Findings:

1) The facility failed to provide a Type I EES comprised of two separate systems: the Emergency System and the Equipment System. The Emergency System shall be divided into the Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3.4.2.2.2 (b) and (c). The Equipment System shall supply power as identified in 3.4.2.2.3.

2) There is no 90 minute emergency back-up lighting over the transfer switch.

Based on observation and interview with staff, the facility failed to provide all exits marked by approved, readily visible signs. Findings:

1) Exit signs were not found at the exterior exits of each of the two patient room wings.

2) Exit signs were not found at each of the patient room wings leading toward the Nurse Station.

Based on observation and interview with staff, the facility failed to provide a smoke barrier of at least one-hour fire rating in accordance with Section 8.3. Findings:

1) An open gap exists in the smoke barrier between the top of the gypsum board and the bottom of the floor deck above.

2) Flammable expanding foam was found around penetrations and voids in the smoke barrier.

3) Open penetrations were found in the smoke barrier.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1, which requires a one-hour rating. Findings:

1) An open gap exists in the wall around hazardous areas between the top of the gypsum board and the bottom of the floor deck above.

2) Flammable expanding foam was found around penetrations and voids in the smoke barrier.

3) Open penetrations were found in the smoke barrier.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 18.5.2.1 and 9.2. Findings:

1) The exhaust fan in a patient room toilet was not operational.

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

1) The main medical gas shut off valves are unlocked and are located in an unrestricted corridor. Shut off valves shall be located to permit access by authorized personnel only (by locating in a ceiling or behind a locked access door) per 4-3.1.2.3 (b).

Based on observation and interview with staff, the facility failed to provide a Type I EES in accordance with NFPA 99, Section 3.4.2.2.2. Findings:

1) The facility failed to provide a Type I EES comprised of two separate systems: the Emergency System and the Equipment System. The Emergency System shall be divided into the Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3.4.2.2.2 (b) and (c). The Equipment System shall supply power as identified in 3.4.2.2.3.

2) There is no 90 minute emergency back-up lighting over the transfer switch.