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Based on staff interview, document review and observation it was determined the facility failed to ensure all essential mechanical, electrical, and patient care equipment is maintained in safe operating condition in accordance with 484.623(b)(1). Facility census 17.

Findings include:

1. In reference to the Federal Life Safety (K0921) tag, the facility failed to inspect patient care related electrical equipment in accordance with NFPA (National Fire Protection Association) 99.

2. In reference to the Federal Life Safety (K0914) tag, the facility failed to conduct electrical safety inspections of the electrical receptacles located at the head of the patient's beds in accordance with NFPA (National Fire Protections Association) 99.

3. In reference to the Federal Life Safety (K0916) tag, the facility failed to provide a remote annunciator for the Generator in accordance with NFPA (National Fire Protection Association) 99.

4. The above mentioned deficiencies were confirmed with the Director of Plant Operations 08/01/18 at approximately 4:30 p.m.

Based on observation, document review and staff interview it was determined dietary staff failed to maintain proper food storage and labeling in accordance with the facility's expectations. Staff failed to label three (3) out of three (3) open food containers in the food storage area. This failure has the potential to adversely impact all patients.

Findings include:

1. Observation of Nutrition Services conducted on 07/30/18 at 1:07 p.m. revealed there were three (3) boxes of opened dried food products located in the food storage area which did not have the date the product was originally opened. One (1) of three (3) opened food products was dated 4/24/18 and the Director of Nutrition Services stated, "This was the date the food product was received."

2. An interview was conducted with the Director of Nutrition Services on 7/31/18 at 3:00 p.m. She stated, "The facility currently does not have a policy concerning the dating of opened foods. Per the Health Department, food that is opened must be thrown away after seven (7) days. Our expectation is for staff to label food with the date opened and discarded within seven (7) days." She concurred the staff was not following department expectations.

Based on document review and staff interview it was determined the facility failed to meet the applicable provisions of National Fire Protections Association (NFPA) 101. Facility census 17.

Findings include:

1. In reference to the Federal Life Safety (K0271) tag, the facility failed to provide an exit discharge for the 700 patient wing in accordance with NFPA 101.

2. In reference to the Federal Life Safety (K0273) tag, the facility failed to provide the dry storage room doors with a closure as required by NFPA 101.

3. In reference to the Federal Life Safety (K0355) tag, the facility failed to provide the proper signage for the "K" fire extinguisher in accordance with NFPA 101.

4. In reference to the Federal Life Safety (K0712) tag, the facility failed to conduct the third quarter evening shift drill in accordance with NFPA 101.

5. In reference to Federal Life Safety (K0511) tag, the facility failed to provide covers for electrical junction boxes in accordance with NFPA 101.

6. The above mentioned deficiencies were confirmed with the Director of Plant Operations and the Administrator on 08/01/18 at approximately 4:30 p.m.

Based on observation and staff interview it was determined the facility failed to maintain a designated clean and soiled storage room in the Emergency Department (ED). This failure has the potential to adversely affect all patients.

Findings include:

1. Observation of the ED on 7/30/18 at 11:55 a.m. revealed a clean storage room with clean supplies, two (2) biohazard waste containers and an umbrella. The staff locker room had a storage rack with clean supplies to be used by the staff. There was no soiled storage room located in the ED.

2. An interview was conducted with the ED Nurse Manager on 7/30/18 at 12:05 p.m. She stated, "She was limited on space." She noted they do not have a designated soiled storage room in the ED.

3. An interview was conducted with the Chief Nursing Officer on 7/30/18 at 2:00 p.m. She concurred the ED does not have a designated soiled storage room in the ED.