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Based on observation and staff interview, the facility does not ensure the integrity of the fire/smoke walls are maintained.

Findings Include:

Observation on 04/05/23 between 11:00 AM and 12:30 PM and on 04/06/23 between 09:00 AM and 12:00 PM revealed penetrations were present in the rated walls throughout the facility. These penetrations were observed in the following locations: in the Pharmacy wall above the audio/visual fire alarm device, around the sprinkler riser pipe that originates on the ground floor and continues through to the 3rd floor in the North stairwell, above the fire doors entering the Urgent Care Center, in the family room / waiting area, in the Medical Care Unit (MCU) in the employee bathroom/storage area, in the PT/OT to MCU stairwell, and in the MCU South stairwell. These penetrations consisted of insulated black pipe, copper piping, sprinkler riser, hot/cold water lines, black drain line and missing bricks.

Interview on 04/05/23 at 12:40 PM and on 04/06/23 at 12:10 PM with Staff (F), Facilities Director, verified these findings.

Based on staff interview, the facility does not ensure that emergency lighting is tested monthly or annually

Findings Include:

On 04/04/23 at 10:30 AM documentation was requested to verify that the emergency lighting was tested, however, the facility failed to provide documentation.

Interview on 04/04/23 at 02:40 PM with Staff (F), Facilities Director, revealed that the facility does not test the emergency lighting monthly or annually. Staff (F) stated that if the facility loses power and the emergency generator is utilized, that certain fluorescent lights remain lit. Staff (F) did not have knowledge if the ballasts were battery operated or which lights remained lit in the event of an electrical power outage.

Based on observation and staff interview, the facility does not ensure that 1 of 2 exit lights is continuously illuminated. (above fire doors into Medical Care Unit (MCU)).

Findings Include:

Observation on 04/06/23 at 09:25 AM revealed that the exit light above the double fire doors into the MCU area was not operational. Exit lights must be continuously lit to ensure proper illumination in the event of an actual emergency.

Interview on 04/06/23 at 09:30 AM with Staff (F), Facilities Director, verified that the bulb in this light was not operational and required replacement.

Based on observation and staff interview, the facility does not ensure that maintenance is performed on the heating, ventilation, and air conditioning system (HVAC) or on the exhaust vents.

Findings Include:

On 04/04/23 at 10:30 AM documentation on HVAC maintenance and the HVAC system's operator's manual were requested, however, the facility failed to provide documentation.

Interview on 04/05/23 at 10:45 AM with Staff (F), Facilities Director, revealed that the facility does not have documentation to verify that routine maintenance has been performed on the HVAC systems or that manuals are available for the systems to determine what maintenance is specifically required on the units. Staff (F) stated that the facility HVAC systems are comprised of two roof top units and two air handling units and that filter changes are performed once per year, but documentation is not maintained when this activity is performed. This maintenance must include, at a minimum, cleaning of the coils, lubricating moving parts, filter changes, inspection of belts, draining and cleaning of the condensate drain. and any other maintenance recommended by the manufacturer per NFPA 90A, 2012 ed.

Observations on 04/05/23 at 11:30 AM and on 04/06/23 at 10:00 AM and 11:15 AM revealed, the mechanical exhaust vents were not operational in the 1st floor janitor's closet, in the Medical Care Unit (MCU) employee toilet room, the MCU storage area, or in the Regulated Medical Waste (RMW) storage area.

Based on observation and interview, the facility does not ensure that the fire doors are tested annually per NFPA 80, 2010 ed. These doors must be tested to ensure proper operation in the event of an emergency.

Findings Include:

On 04/04/23 at 10:30 AM documentation on annual fire door testing was requested, however, the facility failed to provide documentation.

Observation on 04/05/23 at 11:00 AM revealed fire doors were present throughout the facility.

Interview on 04/04/23 at 02:00 PM with Staff (F), Facilities Director, verified that the fire doors have not been tested and indicated that the facility was not aware of the requirement to test fire doors annually.

THIS IS A REPEAT DEFICENCY FROM RECERTIFICATION SURVEY ON 10/19/2018.

Based on observation and staff interview, the facility does not ensure that the piped oxygen system is labeled above the ceiling tiles.

Findings Include:

Observation on 04/05/23 at 11:20 AM, revealed the piping for the central oxygen system and the vacuum system were not labeled above the ceiling tiles. The piping for the oxygen systems must be green/white background with contrasting green/white labeling and the vacuum system must be black/white background with contrasting black/white labeling. The labeling for these systems must be at intervals not exceeding 20 feet.

Interview on 04/05/23 at 01:15 PM with Staff (F), Facilities Director, verified this finding.

THIS IS A REPEAT DEFICENCY FROM RECERTIFICATION SURVEY ON 10/19/2018.

Based on staff interview, the facility does not ensure that the Ground Fault Circuit Interrupters (GFCI) are tested every six months in patient care areas.

Findings Include:

On 04/04/23 at 10:30 AM documentation for Ground Fault Circuit Interrupters (GFCI) testing was requested, however, the facility failed to provide documentation.

Interview on 04/05/23 at 01:10 PM Staff (F), Facilities Director, revealed that the facility does not have documentation to verify that the GFCI's were tested every six months per NFPA 99, 2012 ed. These devices must be tested every six months in patient care areas and annually elsewhere to ensure that the devices do not exceed 10 milliamperes.

Based on document review and staff interview, the facility does not ensure that the generator is tested every three years for four (4) continuous hours or that the electrical panel and the circuits are labeled. Failure to operate the generator for an extended period and to adequately identify the panel and circuits may result in failure of the emergency generator in the event of an actual emergency.

Findings Include:

Review on 04/05/23 at 01:30 PM of the "Emergency Generator Log" revealed no evidence that the generator had been tested every three years for four continuous hours. This log was for the monthly (every 20-40 days) testing of a 30% rated load of the nameplate rating.

Interview on 04/06/23 at 09:15 AM with Staff (F), Facilities Director, indicated that Staff (F) was not aware of this requirement and verified that the generator had not been tested under a full load.

Based on observation and interview, the facility does not ensure the security of 4 of 4 electrical circuit breaker panel boxes throughout the facility. These electrical circuit breaker panel boxes must be secured/locked to prevent unauthorized access.

Findings Include:

Observation on 04/04/23 at 11:00 AM and on 04/05/23 at 11:00 AM revealed that 4 of 4 electrical circuit breaker panel boxes were unlocked and not secured. .Panel box LP-256, panel box in oxygen storage area, panel box in the North stairwell and LP-100. It was also observed that four knock-outs were lacking in the electrical panel in the North stairwell and one knockout was lacking in LP-256 at position #36.

Interview on 04/06/23 at 11:10 AM with Staff (F), Facilities Director, verified this finding.

THIS IS A REPEAT DEFICENCY FROM RECERTIFICATION SURVEY ON 10/19/2018.