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Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive Emergency Preparedness Program (CFR 42 Part 483).

Findings include, but are not limited to:
On 11/12/19, during record review between 2:15 pm and 4:45 pm, the facility failed to develop and implement EP policies and procedures, based on their reported hazard and vulnerability assessment within their established and communicated plan.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive Emergency Preparedness Program (CFR 42 Part 483).

Findings include, but are not limited to:
On 11/12/19, during record review between 2:15 pm and 4:45 pm, the facility failed to provide to this surveyor evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (1)(i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff, capable of supporting the length of time the facility has chosen to shelter-in-place, as identified within the facility's EP plan.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive Emergency Preparedness Program (CFR 42 Part 483).

Findings include, but are not limited to:
On 11/12/19, during record review between 2:15 pm and 4:45 pm, the facility failed to provide evidence to this surveyor of a defined system to track the location of on-duty staff members responsible for providing patient care in the facility during an elongated shelter-in-place event.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive Emergency Preparedness Program (CFR 42 Part 483).

Findings include, but are not limited to:
On 11/12/19, during record review between 2:15 pm and 4:45 pm, the facility failed to document and communicate the necessary training and testing to include, (ii) external sources providing services under agreement, and/or (iii) volunteers, consistent with their expected roles within the EP plan, based on defined all-hazards scenarios.

Surveyor was accompanied by Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.7.5, 9.7.7, 9.7.8, NFPA 70, NFPA 72 and NFPA 25).

Findings include:
On 11/13/19, during record review between 5:16 am and 6:50 am, weekly, and monthly testing and maintenance was being performed by hospital staff and there was no documentation showing technician competence in maintaining its fire alarm system and staff did not have access to the adopted 2010 edition of NFPA 72 standards.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer 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 entire building. This resulted in the potential for system failure during fire emergencies (LSC 19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25, NFPA 2001).

Findings include:
1. On 11/13/19, during record review between 5:16 am and 6:50 am, the facility was unable to produce evidence of the required annual inspection, testing, and maintenance.
2. On 11/13/19, during record review between 5:16 am and 6:50 am, the facility was unable to produce evidence of the required forward flow testing of the fire sprinkler system.
3. On 11/13/19, during record review between 5:16 am and 6:50 am, weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers and staff did not have access to the adopted 2011 edition of NFPA 25 standards.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.4 - 19.7.1.7).

Findings include:
On 11/13/19, during record review between 5:16 am and 6:50 am, facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as, the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, and the specific type of fire simulated.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to ensure that that electrical equipment was maintained in accordance with NFPA 101, NFPA 70, and NFPA 99 within the facility. This resulted in the potential for injury to residents & staff.

Findings include:
On 11/13/19, at 9:06 am, an electrical panel was found obstructed by the storage of combustibles and the clear working space as defined by NFPA 70 110.26 was not observed.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of this condition.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer the facility failed to provide evidence of the required retention testing of electrical plugs within the patient care areas of the facility. This resulted in the potential for injury or damage to equipment or possible injury to residents or staff within the facility in accordance with NFPA 101, NFPA 70, and NFPA 99 6.3.3.2.1-6.3.3.2.4.

Findings include:
On 11/13/19, during record review between 5:16 am and 6:50 am, the facility failed to produce documented evidence of the required annual receptacle retention testing.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility President, Compliance Specialist, and Maintenance Engineer that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 throughout all smoke compartments of the building. This resulted in the potential for injury to residents & staff (LSC 9.1.2, NFPA 99 10.2.3.6, 10.2.4, NFPA 70, TIA 12-5).

Findings include:
On 11/13/19, at 6:57 am, there was a Relocatable Power Tap (RPT) found in-use that was permanently attached to the wall within Treatment Room A that would require a tool to be removed. This process is repeated throughout the facility with several RPT's mounted to the building which are in-use.

Surveyor was accompanied by the Facility President, Compliance Specialist, and Maintenance Engineer who acknowledged the existence of these conditions.