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Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 21 of 21 residents. 1 of 7 corridors had doors that were deficient.

Findings:
During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the door in the corridor between the EVS and Radiology area did not latch in the frame because of a roller latch.

Based on visual observation the facility failed to provide exit signage for all required exits. Exit signs provide a route for occupants to reach safety. The deficient practice had the potential to affect 21 of 21 residents. 3 of 7 exits have signage that is deficient.

Findings:
During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the following areas are missing exit signage (1) - In the corridor by the staff lounge and respiratory storage, (2) - By the lobby bathroom in the corridor leading to Lakeview senior behavioral health unit, (3)- In the corridor by the material director's office.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 21 of 21 residents. 1 of 8 smoke barriers were deficient.

Findings:
During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the smoke barrier by the nurses station on the north wing had a 3/4 inch hole with black wires going through that was not sealed to maintain the rating of the wall.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 21 of 21 residents. 1 of 8 smoke barriers were deficient.

Findings:
During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the cross corridor doors that leads into the suite for H.O.B were not smoke resistive because they did not positive latch in the frame.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 21 of 21 residents. 3 of 7 smoke compartments have hazardous areas that are not separated.

Findings:
1) - During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the respiratory storage room, and the clean utility storage room walls on the north wing were not constructed to resist the passage of smoke because the walls are not constructed completely and have large areas that are not sealed. Some areas that are not sealed to maintain the rating of the barriers range from 2' ft X 4' ft openings to several 3/4"inch down to 3/8"inch openings around metal conduits with wiring going through them. The soiled utility room on the EVS corridor had a 3/8"inch hole that was not sealed to maintain the rating of the wall.

2) - During the facility tour, between the hours of 8:00am and 5:00pm, it was observed , the doors to the medical records storage room and janitor's closet by room #213 were not smoke resistive because of the doors not latching in the frame.

3) - During the facility tour, between the hours of 8:00am and 5:00pm, it was observed , the paint room had a 3' ft X 4' ft opening in the block wall that is sealed on one side of the barrier.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 21 of 21 residents.

Findings:
During the facility tour , between the hours of 8:00am and 5:00pm, it was observed that the following areas did not have audible/visual devices. (1) - Radiology area and the public restrooms in corridor by radiology.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. This deficiency has the potential to affect 21 of 21 residents.

Findings:
1) - During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the sprinkler heads in the material corridor, material director's office and in bathroom of room #217 were painted.

2) - During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the sprinkler escutcheon rings were missing in the coroner's exam room.

3) - During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the ceiling in the old coroner's area of the hospital is missing in several areas and would delay the activation of the sprinkler system in the event of a fire emergency.

Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 21 of 21 residents in the facility. 2 of 8 corridors were deficient.

Findings:
During the facility tour, between the hours of 8:00am and 5:00pm, it was observed that the EVS corridor and the material management corridor had storage that obstructed the exit passageway.