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Based on record review and staff interview, the facility failed to maintain the proper operation of the fire door assemblies in accordance with LSC Section 19.1.1.4.1.2., 8.3.3.1., NFPA 80 (2011). Fire door assemblies that fail 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 5/16/18 from 10:00 am to 12:30 pm revealed that:

1. At 11:35 am during record review, the facility fail to produce documentation for the qualification of maintenance personnel who conducted fire door inspection. According to NFPA 80, fire door inspection shall be conducted by knowledgeable/certified personnel.

An interview with the Maintenance Director (MD) at the time of observation revealed the MD was aware that the fire door inspection was not conducted by a qualified person.

2. At 11:25 am during record review, the facility fail to produce documentation for the fire doors inspection.

An interview with the Maintenance Director (MD) at the time of observation revealed the MD was aware that the fire door inspection was not completed.

NFPA 101 (2012) 19.1.1.4.1.2., 8.3.3.1., NFPA 80 (2011)

These findings were verified by Maintenance Director at the times of observation and the Administrator at the exit conference on 5/16/18 at 4:00 pm.

Based on record review and staff interview, the facility failed to maintain the kitchen hood system in the facility in accordance with LSC Sections 9.2.3, NFPA 96 (2011), NFPA 17A (2009). Failure to maintain the cooking hood equipment endangers patients, staff, and other building occupants.

The findings include:

Record review on 5/16/18 from 10:00 am to 12:30 pm revealed that:

At 11:45 am during record review, the facility failed to produce documentation for the kitchen hood system monthly quick check inspections.

An interview with the Maintenance Dircetor (MD) at the time of the review revealed the MD was aware of the hood system quick check inspections not being completed.

NFPA 101 (2012) 19.3.2.5.2., 9.2.3., NFPA 96 (2011), NFPA 17A (2009) 5.2.

These findings were verified by Maintenance Director at the time of the record review and the Administrator at the exit conference on 5/16/18 at 4:00 pm.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in the facility according to LSC 9.6.1.3., NFPA 72 (2010). Delays from fire alarm system places patients, visitors and staff in danger in case of an emergency.

The finding include:

Record review on 5/16/18 from 10:00 am to 12:30 pm revealed that:

At 10:00 am during record review, facility failed to produce documentation for fire alarm system semi-annual inspections.

An interview with the Maintenance Director (MD) at the time of record review revealed the MD was aware of the fire alarm system semi-annual inspection was not completed.

NFPA 101 (2012) 19.3.4.1., 9.6.1.3., NFPA 72 (2010)

These findings were verified by Maintenance Director at the times of the record review and at the exit conference on 5/16/18 at 4:00 pm

Based on record review and staff interview, the facility failed to maintain electrical receptacles in the facility in accordance with LSC Sections 19.5.1., 9.1.2., NFPA 99 (2012). Faulty receptacles endangers patients, staff, and other building occupants.

The findings include:

Record review on 5/16/18 from 10:00 am to 12:30 pm revealed that:

At 11:55 pm during record review, facility failed to produce documentation for electrical receptacles (GFCI) annual test.

An interview with the Maintenance Director (MD) at the time of the record review revealed the MD was aware of the receptacles test was not completed.

NFPA 101 (2012) 19.5.1, 9.1.2., NFPA 99 (2012) 6.3.2.

These findings were verified by Maintenance Director at the times of the record review and the Administrator at the exit conference on 5/16/18 at 4:00 pm.

Based on record review and staff interview, the facility failed to maintain essential electrical system in the facility in accordance with LSC Sections 19.5.1, 9.1.3., NFPA 70 (2011), NFPA 99 (2012). Overloading of the electrical circuit leads to overheating of wires, short circuits, hot spots, and fire. Endangering patients, staff, and other building occupants.

The findings include:

Record revoew on 5/16/18 from 10:00 am to 12:30 pm revealed that:

At 10:20 am during record review, the facility failed to produce documentation for main feeders circuit breakers inspection and a program for periodically exercising the components established according to manufacturer requirements.

An interview with the Maintenance Director (MD) at the time of the record reveiw, the MD presented a invoice with a letter from a contractor but the code requires a report to show results of the inspection.

NFPA 101 (2012) 19.5.1., 9.1.3., NFPA 70 (2011) 700.10., NFPA 99 (2012) 6.4.4.1.2.1.

These findings were verified by Maintenance Director at the time of the record review and the Administrator at the exit conference on 5/16/18 at 4:00 pm.