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Based upon 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,

In the patient tower, penetrations were found above the corridor doors in the smoke barrier wall that were not properly sealed to maintain the 1/2 hour fire resistance rating in accordance with 8.3.

Based upon observation, interview of staff and review of records the facility failed to provide a written plan for the protection of all patients and for their evacuation in the event of an emergency. 19.7.1.1 Findings,

The facility failed to provide documentation of a written policy on preparedness and emergency drills or action to be taken for tornado preparedness.

Based upon observation and interview of staff and review of records, the facility failed to provide an approved maintenance and testing program of the fire alarm system that is complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings,

The facility failed to provide documentation of a current fire alarm certification or service record the system was maintained to comply with the applicable requirements of NFPA 70 and 72 as noted in 9.6.1.4.

Based upon observation, interview with staff and review of records, the facility failed to provide documentation that the automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5
Findings,

The facility failed to provide documentation of a current fire sprinkler system certification or service records the system was maintained to comply with the applicable requirements of NFPA 70 and 72 as noted in 9.6.1.4.

Based upon observation, interview with staff and review of records, the facility failed to provide proper documentation that relative humidity levels are maintained equal to or greater than 35% NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3


The facility failed to maintain real time documentation of the relative humidity levels at the time of starting a case. Reports were generated after the fact, preventing any corrective action at the time the humidity level might be out of range.

General Findings:
Based upon observation and interview with staff, the facility failed to maintain floor finishes that were clean and sealed in a manner that would not support bacteria and facilitate proper cleaning. Findings,

In the exit corridor by food service, laundry and deliveries there are missing floor tiles leaving dried adhesive surfaces exposed and not maintained in a manner that would not support bacteria and facilitate proper cleaning. There are possible asbestos material in the exposed dried adhesive surfaces.