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Based on observations and interview, the facility failed to maintain the proper operation of the egress door assemblies in accordance with LSC ( Life Safety Code)Section 19.2.2.2.4., 7.2.1.6.1. Egress door assemblies to properly self-close and latch upon release to maintain the fire resistance rated barrier penetration. Failure to maintain the door assembly will allow for the travel of fire and smoke gases from one compartment to another endangering, patients, staff, or other building occupants.

The findings include:
Observations on 11/17/16 from 12:30 PM to 3:15 PM during the tour, revealed that a service corridor /door exit, the egress door had penetrations through it.
During an interview on 11/17/16 at 1:15 PM, the Director of Environmental Services (DES) at the time of observation revealed the DES was aware of the door had penetrations. This did not meet the requirement of NFPA 101 (2012) 19.2.2.2.4., 7.2.1.6.
During an exit conference on 11/17/16 at 3:30 PM. These findings were verified by Director of Environmental Services at the times of observation and with the Administrator.

Based on observations and interview, the facility failed to maintain the self-closers on door assemblies in accordance with LSC( Life Safety Code) Section 19.2.2.2.7. Corridor door assemblies to properly self-close and latch upon release to maintain the fire resistance rated barrier penetration. Failure to maintain the door assembly will allow for the travel of fire and smoke gases from one compartment to another endangering, patients, staff, or other building occupants.

The findings include:
Observations on 11/17/16 from 12:30 PM to 3:15 PM during the tour, a service corridor/ emergency room, the corridor door with self-closer held open by door stop attached to bottom of door.
During an interview on 11/17/16 at 2:55 PM, the Director of Environmental Services (DES) at the time of observation revealed the DES was aware of the door with self-closer was held open by stop. This did not meet the requirement of NFPA 101 (2012) 19.2.2.2.7., 19.2.2.2.8.
During an exit conference on 11/17/16 at 3:30 PM. These findings were verified by Director of Environmental Services at the times of observation and with the Administrator.

Based on observation and staff interview, the facility failed to maintain fire and smoke barriers in the facility in accordance with LSC( Life Safety Codes)Sections 19.3.7.3., 8.3.5.1. which could allow for the transfer of fire and smoke from one compartment to another, endangering patients, staff, and other building occupants.
The findings include:
Observations on 11/17/16 during the tour from 12:30 pm to 3:15 pm revealed that:
Observations on 11/17/16 from 12:30 PM to 3:15 PM during the tour, the boiler/vacuum room, it was that their was penetrations in the wall and ceiling.
During an an interview on 11/17/16 at 2:00 PM, Director of Environmental Services (DES) at the time of observation revealed the DES was aware of the penetrations in the wall. This did not meet the requirement of NFPA 101 (2012) 19.3.7.3., 8.3.5.1.
During an exit conference on 11/17/16 at 3:30 PM. These findings were verified by Director of Environmental Services at the times of observation and with the Administrator.

Based on observation and staff interview, the facility failed to maintain electrical system in the facility in accordance with LSC Sections 19.5.1., 9.1.2., NFPA 99 (2012). Faulty electrical appliances endangers patients, staff, and other building occupants.
The findings include:
During a record review on 11/17/16 at 9:50 AM, the facility fail to produce documentation for main feeders circuit breakers test and exercising.
During an interview on 11/17/16 at 9:55 AM, the Director of Environmental Services(DES) at the time of observation revealed the DES was aware of the main feeder circuit breaker test not completed. This did not meet the requirement of NFPA 101 (2012) 19.5.1, 9.1.2., NFPA 99 (2012) 6.3.2.
Further review of records showed that facility fail to produce documentation for line isolation monitors test.
During an interview on 11/17/16 at 10:05 AM, the Director of Environmental Services(DES) at the time of observation revealed the DES was aware of the line isolation monitors test not completed. This did not meet the requirement of NFPA 101 (2012) 19.5.1, 9.1.2., NFPA 99 (2012) 6.3.2.
During an exit conference on 11/17/16 at 3:30 PM. These findings were verified by Director of Environmental Services at the times of observation and with the Administrator.