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Based on document review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(b)(1)).

Findings include, but are not limited to:
On 04/22/2019, during document review between 13:30 p.m. and 14:30 p.m., the facility failed to provide written documentation in their policies and procedures for how they will notify employees, volunteer,and vendors the need to provide their own pharmaceutical supplies in the event of a shelter in place.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on record review during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for the universe entire building. This resulted in the potential for system failure during fire emergencies (LSC 18/19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25, NFPA 2001).

Findings include, but are not limited to:

1. On 4/22/2019, during record review between 2:30 p.m. and4:00 p.m., there was not a current record of the required 5 year maintenance and testing for the fire sprinkler system.
2. On 4/22/2019, during record review between 2:30 p.m. and4:00 p.m., there was not a current record of the required annual forward flow test of the faclities fire sprinkler system.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that piped in medical gas systems comply with NFPA 99 (NFPA 99 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14. This resulted in the potential for injury to patients during medical procedures.

Findings include but were not limited to:

On 4/22/2019, during record review between 2:30 p.m. and 4:00 p.m., there was no documentation provided showing the required annual testing and maintenance on the Piped Medical Gas System

Surveyor was accompanied by the Maintenance Director who acknowledged the existence these conditions.

Based on observations and interviews it was determined through on-going dialog with the Maintenance Director that the facility failed to properly maintain the electrical system of the facility. This resulted in the potential for the lack of electrical power and a dangerous situation for staff.(LSC 18/19.5, 9.1.2, NFPA 99, NFPA 70).

Findings include, but were not limited to:

1. On 4/23/2019 11:10 p.m., there was an open electrical junction box without a listed cover in the labratory behind the refridgearators.

2. On 4/23/2019 1:35 p.m., there was storage in front of the electrical panels in the kitchen, blocking access to those panels.


Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.