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Document review and interview with the Compliance Officer on 02/26/2018 at 2:28 PM confirmed the facility's emergency plan failed to indicate how the facility would provision subsistence needs for staff and patients whether they evacuate or shelter in place per the requirements of Federal CFR §483.475(c)(3).

The findings include:
Document review and interview with the Compliance Officer on 02/26/2018 at 2:28 PM confirmed the facility's emergency plan failed to indicate provisions of subsistence needs for staff and patients whether they evacuate or shelter in place, include food, water, medical and pharmaceutical supplies

Based on observations, the facility failed to maintain corridor width.

The findings included:

Observation on 02/26/2018 at 12:29 PM, revealed two beds being stored in the corridor at the rear exit outside of the ER and the OR. NFPA 101, 19.2.3.4 (2012 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on observations, the facility failed to protect the hazardous areas.

The findings included:

Observation on 02/26/2018 at 1:27 PM, revealed multiple penetrations by insulated copper pipes in the corridor above the door to plant operations. NFPA 101, 19.3.2.1 (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on interview, the facility failed to protect the cooking facilities.

The findings included:

Interview with kitchen staff member #1 on 02/26/2018 at 12:45 PM, revealed staff member was not knowledgeable of fire control policies for fires under the kitchen hood including manual activation of the hood suppression system. NFPA 101, 19.3.2.5.1 (2012 Edition) NFPA 96, 10.5.7 (2011 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on document review, the facility failed to maintain the fire alarm system.

The findings included:

Document review on 02/26/2018 at 11:54 AM, revealed the facility failed to provide documentation for the annual fire alarm inspection during 2017. NFPA 101, 19.3.2.5.3(11) (2012 Edition) NFPA 72, Table 14.4.5 (2010 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on document review, on the facility failed to maintain the sprinkler system.

The findings included:

1. Document review on 02/26/2018 at 11:45 AM, revealed the facility failed to provide documentation for the quarterly sprinkler during the 2nd quarter of 2017. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.1.1 (2012 Edition) NFPA 13, 24.6.1 (2010 Edition) NFPA 25, 5.1.1.2 (2011 Edition)

2. Document review on 02/26/2018 at 11:48 AM, revealed the facility failed to provide documentation for the five year internal sprinkler obstruction investigation. NFPA 101, 19.3.5.1 (2012 Edition) NFPA 101, 9.7.1.1 (2012 Edition) NFPA 13, 24.6.1 (2010 Edition) NFPA 25, 14.2.1 (2011 Edition) NFPA 25, 14.2.1.4 (2011 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on observation, the facility failed to maintain the medical gas piping.

The findings included:

Observation on 02/26/2017 at 2:01 PM, revealed the rigid metal conduit contacting the copper medical gas piping above the ceiling outside of the medical lab by the electrical panel closet. NFPA 99, 5.1.10.11.4.2 (2012 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on document review, the facility failed to maintain the emergency power generation system.

The findings included:

1. Document review on 02/26/2018 at 11:50 AM, revealed the facility failed to conduct the annual 1½ hour generator load bank test during 2017. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.3.1 (2012 Edition) NFPA 110, 8.4.2 (2010 Edition) NFPA 110, 8.4.2.3 (2010 Edition)

2. Document review on 02/26/2018 at 11:52 AM, revealed the facility failed to conduct the three year 4 hour continuous generator run. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.3.1 (2012 Edition) NFPA 110, 8.4.9 (2010 Edition)

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.

Based on observations, the facility failed to comply with power-strip and extension cord regulations.

The findings included:

Observation on 02/26/2018 at 1:06 PM, revealed an unapproved power-strip in OR 1 (under computer station; not labeled UL1363). NFPA 99, 10.5.2.3.1 (2012 Edition) NFPA 99, 10.2.4 (2012 Edition) CMS S&C 14-46

Maintenance staff was present when these deficiencies were identified and the administrator acknowledged these deficiencies during the exit conference on 02/26/2018.