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Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to maintain the integrity of smoke separations for the building. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 8/17/2016, during the facility tour between 10:30 a.m. and 5:00 p.m., there were unsealed ceiling penetrations measuring approximately 1/2" in diameter adjacent to newly installed AC Units in multiple areas/rooms of the facility. Areas and Rooms include but not limited to: Main Hospital Lobby, Patient Rooms, and Offices. This unsealed ceiling penetration would allow products of combustion (heat and smoke) into the attic space of the facility.
2. On 8/17/2016, at 11:35 a.m., there was a unsealed ceiling penetration that measured approximately 2" in diameter within the SE corner of the X-Ray room. The unsealed ceiling penetration would allow products of combustion (heat and smoke) into the attic space of the facility.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into other areas of the facility, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 8/17/2016, during the facility tour between 10:30 a.m. and 5:00 p.m., there were multiple unsealed penetrations found within smoke separation walls within the attic space of the facility. Unsealed smoke separation wall penetrations ranged in size from approximately 1/2" diameter to 4" in diameter and rectangular penetrations approximately 1/2" x 36". These unsealed smoke separation penetrations would allow for the migration of products of combustion (smoke and heat) into other smoke compartments of the building during a fire event and not confine the fire event to the originating smoke compartment. Smoke separation walls include but were not limited to: North smoke compartment wall, South smoke compartment wall, Central smoke compartment wall, and Smoke compartment wall over Administration. *SEE NOTE.
2. On 8/17/2016, during the facility tour between 10:30 a.m. and 5:00 p.m., there were smoke barrier doors within the attic space that were not closing or latching properly when tested by the surveyor. Doors include but were not limited to: South smoke barrier wall, smoke barrier door over the Lab, and smoke barrier door over the Oxygen room.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: This was a repeat deficiency from the survey completed on September 21, 2011 from 11:57 a.m. to 2:10 p.m. The survey identified the attic space of the facility having unsealed penetrations throughout the attic space.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed maintain stairway enclosure doors. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19.2.2.3, 7.2.1.8.2). Findings include, but are not limited to:
1. On 8/17/2016, at 11:02 a.m., the stairwell door within the LTC Wing of the building, adjacent to Resident Rm. 212, did not close or latch completley when tested by the surveyor.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2, 8.4). Findings include, but are not limited to:
1. On 8/17/2016, at 11:43 a.m., there was a door leading to the soiled linen/hopper room within the Emergency Department that was not closing or latching properly when tested by the surveyor.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to install/maintain exit access and exit doors with an approved clear width to accommodate the patients served 32" existing (Ch. 19) facilities or 41.5" new (Ch. 18) facilities. This resulted in the potential for panic and injury to residents/patients & staff during emergency evacuations and relocation (LSC 18.2.3.5). Findings include, but are not limited to:
1. On 8/17/2016, during the facility tour between 10:30 a.m. and 5:00 p.m., there were (2) exterior egress glass doors at the end of the south corridor from the LTC Wing of the building that had been remodeled after March 2003 that did not meet the minimum 41.5" clear width measurement as required by Chapter 18 of NFPA 101. Facility staff mentioned that they had a CMS Waiver for the two doors but were unable to locate during the survey. Both doors measured 34" in clear width.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually for the facility. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on battery powered emergency lights within the facility.
2. On 8/17/2016, at 11:55 a.m., the Procedure Room for the facility was missing a battery powered emergency light that would illuminate the Procedure Room for a minimum of 90-minutes in the event of a power outage and emergency generator failure.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the disaster plan provided by the facility to the surveyor had an annual review date of December 2011, and was past due for annual review since December 2012. *SEE NOTE.
2. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the disaster plan provided by the facility to the surveyor was incomplete. The plan was missing the following items: a Hazard Vulnerability Assessment specific to hazards that would be encountered by the facility; Facility map showing the locations the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event, and no emergency policy/procedure in the event of a damn failure. *SEE NOTE.
3. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., documentation provided by the facility showed the last two emergency preparedness drills were conducted on 11/2014 and 2/2015. Facility was required to conduct a minimum of two emergency preparedness drills within a 12 month period of time.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: These deficiencies were a repeat deficiency from the survey conducted on September 21, 2011, during record review. The survey identified the following deficiencies: Disaster Manual was past due for review, the absence of a facility utility shutoff map, the absence of a Hazard Risk Assessment, and the absence of policies and procedures for emergency events that may be encountered by the facility.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff 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 18/19.7.1.2, A.18/19.7.1.2). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the facility did not have record of conducting their 3rd quarter Night Shift Drill for 2015.
2. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to: 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, specific type of fire simulated, specific location of simulated fire and Staff Performance during the drill. *SEE NOTE.
3. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., fire drill documentation presented to the surveyor showed that fire drills during the time frames of 6 a.m. and 9 p.m., staff were conducting "silent" fire drills. Surveyor asked EMS Coordinator what a "silent drill" was and the EMS Coordinator mentioned that they did not set off the fire alarm system because it would disturb the patients within the facility.
4. On 8/17/2016, at 2:15 p.m., the surveyor had the EMS Coordinator conducted a fire drill within the Emergency Department Exam Room. The following observations were made by the surveyor: Nursing Staff had to be coached by the surveyor and EMS Coordinator to utilize the fire alarm pull station; Nursing Staff were complacent in responding to the direction of the EMS Coordinator; Nursing Staff did not clear the egress corridor within the Emergency Department Area (left a X-Ray machine and cart in the corridor); Nursing Staff did not search/clear all rooms within the smoke compartment; Nursing Staff did not know the location of the fire alarm pull stations; Nursing Staff did not simulate the evacuation of patients from the affected smoke compartment; and Nursing Staff wanted to talk about what they would do in the event of a fire instead of actually doing the actions.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: This was a repeat deficiency from the survey conducted on September 21, 2011 at 11:26 a.m., which mentioned that, fire drill forms were found to be incomplete in detail.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 8/17/2016, at 10:40 a.m., the electrical panel housing the breaker for the FACP was not labeled in red and did not have a mechanical set screw lock on the FACP breaker.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to test and maintain the 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 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., there was no documentation provided by the facility showing the required annual testing and maintenance on the fire alarm system. The last annual fire alarm testing/maintenance was conducted on 6/25/2014 and was past due since 6/25/2015. *SEE NOTE.
2. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., monthly and quarterly testing and maintenance was not being performed and there was no documentation showing technician competence in maintaining the fire alarm system and staff did not have access to the adopted 1999 edition of NFPA 72 standards. EMS Coordinator mentioned that facility staff maintain/inspect the fire alarm panel but there was no documentation showing the maintenance/inspection. *SEE NOTE.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: These were repeat deficiencies from the survey conducted on September 21, 2011 at 11:24 a.m. and 3:10 p.m. The survey identified that the facility failed to maintain the facilities fire alarm system on a monthly, quarterly and annual basis. During the September 21, 2011 survey the survey identified that the annual inspection and maintenance was never completed after a new fire alarm system was installed in 2008 and only a repair was completed in June 2011. Survey also identified the absence of the required NFPA 72 standard and Technician Competence for staff when maintaining the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 8/17/2016, at 10:46 a.m., there was missing automatic sprinkler coverage within the Candy Closet within the Main Lobby of the facility.
2. On 8/17/2016, at 10:51 a.m., the spare sprinkler cabinet adjacent to the main sprinkler riser was missing the required spare stock of sprinkler heads. The facility was required to maintain a minimum of 2-spare sprinkler heads for each type and temperature within the facility. The sprinkler cabinet did not have spare concealed sprinkler heads and pendent heads.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., weekly, monthly, and quarterly testing and maintenance was not 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 1998 edition of NFPA 25 standards. EMS Coordinator mentioned that the testing and maintenance on the sprinkler system was not being documented. *SEE NOTE.
2. On 8/16/2016, at 11:06 a.m., there were 3-4 exterior automatic sprinkler heads that were painted that were located between the Shop and LTC Wing that shall be replaced.
3. On 8/16/2016, at 11:12 a.m., there was a damaged automatic sprinkler head within the walk-in freezer in the Facilities Kitchen that shall be replaced.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: This was a repeat deficiency from the survey that was conducted on September 21, 2011. The survey identified that weekly, monthly and quarterly inspection and maintenance on the fire sprinkler system had not been conducted. Survey also identified the absence of NFPA 25 and Staff Technician Competence for conducting inspection and maintenance on the fire sprinkler system.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system, last test was conducted on 9/26/2011 and was past due since 9/26/2012. *SEE NOTE.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: This was a repeat deficiency from the September 21, 2011 survey conducted at 3:10 p.m. The survey noted, that the automatic sprinkler system had not been maintained or tested since 2008. Facility was unable to provide of documentation or evidence of maintenance and testing as required by NFPA 25.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for extinguishers in the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., monthly inspections were being performed by staff and staff did not have access to the adopted 1998 edition of NFPA 10 standards. *SEE NOTE.
2. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the facility did not retain the previous 3-years of fire extinguisher inspection tags.
3. On 8/17/2016, at 11:13 a.m., there was not a minimum 4A 40B:C fire extinguisher in the kitchen of the facility only a 2A:K and 10B:C fire extinguishers were located.
4. On 8/17/2016, at 11:34 a.m., there was a fire extinguisher within the X-Ray Technicians Room that was not securely installed by use of supplied hangers or brackets as specified in NFPA 10. The fire extinguisher within the X-Ray Tech. Rm. was sitting on a countertop in a free standing arrangement and not securely installed.
5. On 8/17/2016, at 11:41 a.m., the fire extinguisher within the Lab was past due for the required annual service. The service tag on the fire extinguisher was punched for May 2014 and was past due for service since May 2015.
6. On 8/17/2016, at 11:51 a.m., there was a fire extinguisher within the Administration Office on the Main floor of the facility that was installed more then 60" from the finish floor to the handle.
7. On 8/17/2016, at 12:15 p.m., there was a fire extinguisher within the corridor outside of the Home Health Office on the Lower Level of the facility that was installed more then 60" from the finish floor to the handle. *SEE NOTE.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: These deficiencies were repeat deficiencies from the survey conducted on September 21, 2011 at 11:24 a.m. and 11:57 a.m. The survey identified the absence of the required NFPA 10 manual for staff reference in conducting monthly inspections on the fire extinguishers and the installation of fire extinguishers over 60" from the finish floor on the lower level.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to maintain an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the facility had no documentation showing the required semi-annual and annual kitchen hood/suppression inspection and maintenance testing as required by NFPA 96.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of the following conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 8/17/2016, at 11:50 a.m., there was a space heater within the Administration Area (main level) that was labeled as household use only.
2. On 8/17/2016, at 12:10 p.m., there was a space heater within the Home Health Office (lower level) that was labeled as household use only.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections for corridors of the building. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 8/17/2016, at 11:36 a.m., there was a portable X-Ray Machine within the ED Corridor that projected into the constructed clear width of the egress corridor which reduced the corridor below the required 8'. *SEE NOTE.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

*NOTE: This was a repeat deficiency from the survey conducted on September 21, 2011 at 12:23 p.m., which identified the X-Ray machine as a corridor obstruction reducing the corridor width below the required 8' within the ED Corridor/Hallway.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to provide safe storage for compressed gas in the exterior oxygen storage area of the facility. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
1. On 8/17/2016, at 10:29 a.m., there were 5-compressed gas cylinders that were not properly secured by evidence of a single chain near the top of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the Exterior Med. Gas storage room during a seismic event. *SEE NOTE.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 18/19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
1. On 8/17/2016, at 11:08 a.m., there were oxygen cylinders stored within the Clean Storage adjacent to the LTC Nurse Station that had electrical switches and outlets within 60" of the finish floor.
2. On 8/17/2016, at 11:26 a.m., there were oxygen cylinders stored within the Storage Closet adjacent to the Attic Stairwell that had electrical switches and outlets within 60" of the finish floor.
3. On 8/17/2016, at 11:43 a.m., there were oxygen cylinders stored within the ED Hopper Rm. that had electrical switches and outlets within 60" of the finish floor.
4. On 8/17/2016, at 12:04 p.m., there were oxygen cylinder stored within the Home Health Storage Closet that had electrical switches and outlets within 60" of the finish floor.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions

*NOTE: This was a repeat deficiency from the survey conducted on September 21, 2011 at 12:12 p.m., which identified the absence of two chains for securing oxygen cylinders within the Exterior Oxygen Storage Area.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., there was no documentation provided showing the required semi-annual, annual or bi-annual testing and maintenance on the entire Piped Medical Gas System. Last tested was conducted on 12/10/2011 and was past due since 12/10/2012 or 12/10/2014. Testing and maintenance for the Piped Medical Gas System encompasses the entire system which includes items such as but not limited to: Master Signal Panels, Area Alarms, Automatic Pressure switches, Shut-Off Valves, Flexible connectors and Outlets as defined in NFPA 99.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the facility did not have a Humidity Policy/Procedure that identified the reasoning for not having to monitor humidity levels within the Procedure Room of the facility. During an interview with Hospital Staff, staff mentioned that they do not use any type of gas sedation within the hospital.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to properly maintain the generator affecting the entire facility. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator and staff did not have access to the adopted 1999 edition of NFPA 110 standards. *SEE NOTE.
2. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., facility did not have current documentation for the required 3-yr. 4-hr. load bank test. Last 3-yr. 4-hr. load bank test on the generator was conducted on 9/26/2011 and was past due since 9/26/2014. *SEE NOTE.
3. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., the facility did not have documentation of conducting weekly electrolyte/water level testing/checks and monthly specific gravity testing/checks as required by NFPA 110. *SEE NOTE.
4. On 8/16/2016, at 10:24 a.m., the facilities emergency generator was equipped with maintenance free batteries which would prevent the facility from performing weekly and monthly testing and maintenance as required by NFPA 110.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.


*NOTE: These deficiencies were repeat deficiencies from the survey conducted on September 21, 2011 at 11:24 a.m., 12:14 p.m. and 3:10 p.m., which identified the absence of staff technician competence in maintaining the emergency generator, access to NFPA 110 for reference in maintaining the emergency generator, the absence of the required 3-yr. 4-hr. load bank test and the absence of weekly water/electrolyte level testing/checks and monthly specific gravity testing/checks.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and patients in a power outage. Findings include, but are not limited to:
1. On 8/16/2016, during record review between 11:00 a.m. and 5:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.
2. On 8/17/2016, at 10:22 a.m., the emergency battery powered task illumination light within the electrical room that housed the automatic transfer switch equipment for the facilities emergency generator did not work when tested by the surveyor.
3. On 8/17/2016, at 10:25 a.m., the emergency battery powered task illumination light within the facilities emergency generator enclosure did not work when tested by the surveyor.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building. This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 8/17/2016, at 10:40 a.m., the breaker controlling the Fire Alarm Control Panel was painted and shall be replaced.
2. On 8/17/2016, at 10:42 a.m., there were open areas between electrical breakers within Electrical Panel F located in the main facility electrical room.
3. On 8/17/2016, at 11:42 a.m., there were open areas between electrical breakers within Electrical Panel BB located in the Lab Overflow Rm.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition of the building. This resulted in the potential for injury to residents and staff (LSC 19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:
1. On 8/17/2016, at 11:43 a.m., there was an Alcohol Based Hand Rub (ABHR) dispenser that was installed above an electrical switch within the ED Exam Room.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.