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Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 21, 2021, at 9:47 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes a system policy for medical documentation transportation in the event of an emergency.

Interview with the fire marshal on April 21, 2021, at 9:47 a.m., confirmed the Emergency Preparedness Plan did not include the above element.

Based on observation and interview, the facility failed to ensure the division of building construction types on one of four building levels.
Findings include:
1. Observation on April 21, 2021, between 10:46 a.m. and 11:47 a.m., revealed the following
A. (10:46 a.m.) north wing, second floor, above the fire doors separating the north and center wings, had an unsealed penetration around data cables;
B. (11:47 a.m.) south wing, second floor, fire wall separating south and center wings, had an unsealed penetration around a section of conduit.

Interview with the facility maintenance manager and facility safety manager on April 21, 2021, at 11:47 a.m., confirmed the above penetrations existed in the rated walls.

Based on observation and interview, the facility failed to maintain building construction type in one of four building levels.

Findings include:

1. Observation on April 21, 2021, between 10:40 a.m. and 11:40 a.m., revealed the following building construction deficiencies:
A. (10:40 a.m.) north wing, second floor, door 210, had unrated insulation being used in a floor penetration;
B. (11:05 a.m.) north wing, second floor, door 219, had unsealed penetrations around two copper lines protruding through the floor;
C. (11:25 a.m.) north wing, second floor, door 268, had an unsealed penetration around communication cables located in the ceiling;
D. (11:40 a.m.) south wing, second floor, above the fire doors, next to room 201, had an unsealed penetration around data cables.

Interview with the facility maintenance manager and facility safety manager on April 21, 2021, at 11:40 a.m., confirmed the above building construction deficiencies existed.

Based on observation and interview, the facility failed to maintain one of one emergency exits.

Findings include:

Observation on April 21, 2021, at 1:06 p.m.., revealed the discharge exit did not maintain a hard packed all-weather travel surface to a public way.

Interview with the fire marshal on April 21, 2021, at 1:06 p.m., confirmed the above exit discharge deficiencies.

Based on document review and interview, it was determined that the facility failed to remain in compliance with the emergency lighting requirements in one of one buildings.

Findings include:

Observation on April 21, 2021, at 10:32 a.m., revealed the facility's emergency lighting documentation lacked the annual 90 minute test, at the time of the survey.

Interview with the fire marshal on April 21, 2021, at 10:32 a.m., confirmed the facility's emergency lighting 90 minute testing documentation was not available, at the time of the survey.

Based on observation and interview, the facility failed to maintain one of one hazardous areas.

Findings include:

Observation on April 21, 2021, at 1:04 p.m., revealed the laundry room door would not close in the frame.

Interview with the fire marshal on April 21, 2021, at 1:04 p.m., confirmed the laundry room door would not close in the frame.

Based on observation and interview, the facility failed to maintain portable fire extinguishers on one of four building levels.

Findings include:

1. Observation on April 22, 2021, at 10:35 a.m., revealed room 397, had a fire extinguisher that was not properly mounted in the designated area.

Interview with the facilities maintenance manager, on April 22, 2021, at 10:35 a.m., confirmed the above fire extinguisher was not properly mounted.

Based on document review and interview, the facility failed to maintain heating, ventilation, and air conditioning components for one of one component.

Findings include:

1. Document review on April 21, 2021, at 10:00 a.m., revealed the six-year fire damper inspection documentation was not available, at the time of the survey.

Interview with the fire marshal on April 21, 2021, at 10:00 a.m., confirmed the fire damper inspection report was not available at the time of the survey.

Based on document review and interview, the facility failed to maintain heating, ventilation, and air conditioning components for one of one component.

Findings include:

1. Document review on April 21, at 10:00 a.m., revealed the six-year fire damper inspection documentation was not available, at the time of the survey.

Interview with the fire marshal on April 21, at 10:00 a.m., confirmed the fire damper inspection report was not available, at the time of the survey.

Based on document review and interview, it was determined that the facility failed to perform fire drills as directed by regulations for one of one building.

Findings include:

Observation on April 21, 2021, at 11:42 a.m., revealed the facility's fire drill documentation, was inconclusive in demonstrating fire drills were conducted at varied and unexpected times once per shift, per quarter.

Interview with the fire marshal on April 21, 2021, at 11:42 a.m., confirmed the facility's fire drills inconclusive.

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements per NFPA 70 and NFPA 99, on two of four levels.

Findings include:

1. Observation on April 21, 2021, between 10:34 a.m. and 12:22 p.m., revealed the following electrical deficiencies:
A. (10:34 a.m.) north wing, second floor, dayroom closet, door 209, had a light switch that was missing faceplate;
B. (10:35 a.m.) north wing, second floor, dayroom, door 240, had a receptacle that was missing the faceplate;
C. (10:47 a.m.) north wing, second floor, smoke doors next to patient room 200, above the lay-in ceiling tiles, had a cover plate missing, from a junction box;
D. (11:11 a.m.) north wing, second floor, outside door 256, had an electrical breaker panel that was missing the "dead front" protective cover;
E. (11:31 a.m.) north wing, second floor, med room, door 278, had insulation separating from the plug end on a cord;
F. (11:40 a.m.) south wing, second floor, outside patient room 201, above the lay-in ceiling tiles, had two junction boxes missing the cover plates;
G. (11:46 a.m.) south wing, second floor, door 290, had an electrical breaker panel that was missing the "dead front" protective cover;
H. (12:22 p.m.) south wing, third floor, door 332A, had an electrical breaker panel that was missing the "dead front" protective cover.

Reference: NFPA 70-406.6, NFPA 70-314.28(C), NFPA 70-408.38, and NFPA 70-400.3

Interview with the facility maintenance manager and facility safety manager on April 21, 2021, at 11:46 a.m., confirmed the electrical system deficiencies listed above existed.
2. Observation on April 22, 2021, between 10:10 a.m. and 10:41 a.m., revealed the following electrical deficiencies:
A. (10:10 a.m.) north wing, third floor, bathroom door 326, had a section of unprotected "SO" cable, routed through the wall, to the corridor drinking fountain;
B. (10:21 a.m.) north wing, third floor, closet next to door 353, had a section of unprotected "SO" cable with a male plug end routed through the wall, to the corridor drinking fountain;
C. (10:25 a.m.) north wing, third floor, door 385, above the lay-in ceiling tiles, had a junction box approximately 18" x 10" that was missing the cover plate;
D. (10:41 a.m.) north wing, third floor, door 3403, above the lay-in ceiling tile, had a junction box that was missing the cover plate.

Reference: NFPA 70-400.3 and NFPA 70-314.28(C)

Interview with the facility maintenance manager on April 22, 2021, at 10:41 a.m., confirmed the electrical system deficiencies listed above existed.

Based on observation and interview, the facility failed to maintain electrical receptacles on two of four levels.

Findings include:

1. Observation on April 21, 2021, between 11:11 a.m. and 12:22 p.m., revealed the following electrical receptacle deficiencies:
A. (11:11 a.m.) north wing, second floor, snack room, door 256, had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle;
B. (11:45 a.m.) south wing, second floor, snack room, door 233, had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle;
C. (12:22 p.m.) south wing, third floor, snack room, door 332A, had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle.

Interview with the facility maintenance manager and facility safety manager on April 21, 2021, at 12:22 p.m., confirmed the above receptacle deficiencies existed.

2. Observation on April 22, 2021, between 10:35 a.m. and 10:45 a.m., revealed the following electrical receptacle deficiencies:
A. (10:35 a.m.) north wing, third floor, door 377, had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle;
B. (10:45 a.m.) north wing, third floor, door 3400, had an outlet located near a sink that was not protected by a ground fault circuit interrupter (GFCI) receptacle.

Interview with the facility maintenance manager on April 22, 2021, at 10:45 a.m., confirmed the above receptacle deficiencies existed.

Based on observation, document review and interview, the facility failed to maintain essential electrical systems for one of one components.

Findings include:

1. Document review on April 21, 2021 at 9:49 a.m., revealed the facility lacked the following documentation for the emergency generator continuous four-hour exercise, every thirty-six months.

Interview with the fire marshal on April 21, 2021 at 9:49 a.m., confirmed the above generator documentation was unavailable at the time of the survey.

2. Observation on April 20, 2021, at 1:02 p.m., revealed both emergency generators servicing the north and south wings of the building, lacked a remote manual stop station, in accordance with NFPA 110, 5.6.5.6.

Interview with the fire marshal on April 21, 2021 at 1:02 p.m., confirmed the emergency generator lacked a remote manual stop station.

Based on observation, document review and interview, the facility failed to maintain essential electrical systems for one of one components.

Findings include:

1. Document review on April 21, 2021, at 9:49 a.m., revealed the facility lacked the following documentation for the emergency generator continuous four-hour exercise, every thirty-six months.

Interview with the fire marshal on April 21, 2021, at 9:49 a.m., confirmed the above generator documentation was unavailable, at the time of the survey.

2. Observation on April 20, 2021, at 1:02 p.m., revealed the emergency generator servicing this building, lacked a remote manual stop station, in accordance with NFPA 110, 5.6.5.6.

Interview with the fire marshal on April 21, 2021, at 1:02 p.m., confirmed the emergency generator lacked a remote manual stop station.

Based on observation and interview, the facility failed to maintain electrical power cords on two of four floors.

Findings include:

1. Observation on April 21, 2021, between 10:49 a.m. and 12:26 p.m., revealed the following electrical power cords were deficient:
A. (10:49 a.m.) north wing, second floor office, door 230, had an air conditioning unit that was plugged into a surge protector;
B. (11:06 a.m.) north wing, second floor, nurse's office, door 249, had an air conditioning unit that was plugged into an extension cord;
C. (12:26 p.m.) south wing, third floor, door 331, had a Keurig coffee pot plugged into a surge protector.

Interview with the facility maintenance manager and facility safety manager on April 21, 2021, at 12:26 p.m., confirmed the electrical power cords were not in compliance.