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Based upon observation and interview with staff, the facility failed to provide smoke barriers constructed of at least one half hour fire resistance ratting that are continuous through all concealed spaces, such as those found above a ceiling, as required by 8.3, 19.3.7.3. Findings,

The smoke barriers had unsealed penetrations, missing drywall material in several locations; including, but not limited to, the barrier between the Administrative Area and the Lobby, the wall beyond the Reception Counter - including a breach in the rated drywall with unit-strut at the roof drain, causing gaps in the rated material. Other areas included the walls above the ceiling either side of the Commons where the piping and conduit to the new addition breaches both walls. Also, the wall separating the Entry Vestibule to the Commons and the adjacent Smoke Compartment had missing drywall where the ductwork penetrates the walls. Other findings were areas where the flutes in the steel deck were not properly sealed where passing over the rated wall and minor pipe penetrations that were not sealed - all as noted to the facility staff during the Survey.

Based on observation and interview with staff, the facility failed to provide Exit and directional signs that are displayed in accordance with section 7.10 . Findings,

The exit sign located on the 2nd floor, west side, is facing west and does not have visible letters depicting EXIT or a directional indicator, as required by 7.10.2 & 7.10.3.

Based on observation and interview with staff, the facility failed to provide Electronic or written records of tests that are in accordance with NFPA 72 . Findings,

The current annual fire alarm test records were not signed by the person conducting the test or a representative of the facility. Also, the test records failed to have applicable information in accordance with chapter 7-5.2.2; including, but not limited to, the date, test frequency, name of property and address.

Based upon observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. 9.6.1.4. Findings,

Records of a fire drill conducted on 9-16-09 noted that speakers in the main Dinning Room and in Riccardo's could not be heard. The facility has failed to maintain these speakers and has not taken corrective action.

Based on observation and interview with staff, the facility failed to provide a automatic sprinkler system, that is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building as required by 19.3.5, Findings:

The walk-in freezer and coolers located in the kitchen, had combustible materials stored to the ceiling, which prevented the sprinkler head from providing full coverage to the entire area.

Based on observation and interview with staff, the facility failed to provide protection for anesthetizing locations in accordance with NFPA 99, Standards for Health Care Facilities as required by NFPA 101, 19.3.2.3. Findings,

OR Rooms 4 & 5 failed to provide smoke detectors and the equipment to automatically vent products of combustion in accordance with NFPA 99 1999 Edition Chapter 5-4.1.3. They did not have smoke detectors or the HVAC set up to go into exhaust mode.