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Based on observations and interviews it was determined that the facility failed to perform monthly inspecting and testing of the existing elevator to conform to NFPA 99 2012 15.5.3.4, ASME A17.1. Findings include, but are not limited to:

1. On 01/29/2018, at 11:25 a.m., it was noted the maintenance director indicated there was not an inspection policy and procedure written out or a monthly inspection being conducted of the elevator.

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

Based on observations, interviews and record review, it was determined that the facility failed to provide fire drills for all staff affecting the entire building (s). This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 20/21.7.1., 20/21.7.2, 20/21.7.2.2, 20/21.7.2.3). Findings include, but were not limited to:

1. On 01/29/2018, during record review between 1400 and 1645, it was noted fire drill records showed that no documentation had been entered to account for the length of time required to complete the fire drills in 2017 and 2018 year to date.

Facility documentation presented to the surveyor revealed incomplete fire drill information on the facility. Fire drill report forms were missing the length of time required to complete the conducted fire drills.

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 that the facility failed to ensure that no combustibles or decorations of highly flammable characteristics were stored or used, unless in limited quantities or flame retardant for the basement area of building 2. This resulted in the potential for excessive fire spread (LSC 19/18.7.5.6, 18/19.7.5.6, and NFPA 701). Findings include, but were not limited to:

1. On 01/30/18 /2017, at 13:45 p.m., it was noted combustible storage in the basement area of building 2.
The storage consisted of a buildup of combustible materials to include cardboard boxes, miscellaneous plastic and wood items.

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 that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for OR surgery areas within the hospital main 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, but were not limited to:

1. On 01/30/2017, at 10:40 a.m., it was noted that an extension cords were in use on OR-2 and OR-3.
2. On 01/30/2017, at 10:45 a.m., it was noted that an approved RPT in OR-2 was in use providing power source to a moveable equipment assembly but not permanently attached to the assembly.
3. On 01/30/2017, at 10:50 a.m., it was noted that extension cords were stored in the low voltage room. According to the maintenance director, the intent for the extensions cords is to provide power for televisions in patient rooms in the event of a power outage that leads to the use of emergency backup power.

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