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Based on record review and interview made in the presence of the facility manager on 05-02-2022 it was determined that the facility failed to develop and implement emergency policies and procedures, based on their emergency plan set forth in the risk assessment risk assessment. The policies and procedures must be revied and updated at least annually.

This deficiency affected 1 of the required emergency preparedness programs.

Findings include:
1-During the record review it was discovered that the facility did not develop and maintain a comprehensive emergency preparedness program in accordance with Title 42, Code of Federal Regulations, 483.73. That was revied and updated annually.

Based on record review and interview made in the presence of the facility manager on 05-02-2022 it was determined that the facility failed to develop and maintain an emergency policy and procedure for the provision of substance needs for staff and patients weather they evacuate or shelter in place.

This deficiency affected 1 of the required emergency preparedness programs.

Findings include:
1-During the record review it was discovered that the facility failed to develop and maintain an emergency policy and procedure for their Sewage and waste disposal in accordance with Title 42, Code of Federal Regulations, 483.73.

Based upon observations made during the facility tour in the presence of the facility manager on 05-02-2022 it was discovered that the facility did not maintain the means of egress, Exit discharge in accordance with NFPA 101 19.2.11, 19.2.1, 7.1.10.1.

This deficiency affected the basement exit corridor

Findings include:
1-During the facility tour it was discovered that there was storage of several items on both sides of the basement exit discharge corridor, these finding were confirmed with the facility manager. And not in accordance with Exit discharges NFPA 101 19.2.11, 19.2.1, 7.1.10.1

Based upon observations made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not maintain the Fire/smoke control doors so that they shut to resist the passage of Fire/smoke in accordance with NFPA101 19.2.2.2.6.

This deficiency affected 2 of several rated doors

Findings include:
1-The rated door in the sterile core corridor was blocked open with a wedge and could not shut to prevent the passage of fire/smoke at the time of this survey in accordance with NFPA 19.2.2.2.2, 19.2.2.2.8
2-The rated corridor door into the dirty C.P. room was blocked open with a wedge and could not shut all the way to prevent the passage of fire/smoke at the time of this survey in accordance with NFPA 19.2.2.2.2, 19.2.2.2.8

Based upon observations made in the presence of the facility manager on 05-02-2022 it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1, 20.2.9existing and 7.9)

This deficiency affected all emergency lights.

Findings include:
During the record review the facility failed to provide the documentation for the 30 second tests report for the following months, Jan, Feb, March, April, May, June, July, Aug and Oct monthly 30 second tests of the emergency lights with battery backup, in accordance with NFPA 101 7.9.3.

Based upon observations made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

This deficiency affected several rated walls

Findings include:
1-During the facility tour it was observed that the rated fire/smoke walls in the basement boiler/mechanical room had penetrations and were not fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1
2-During the facility tour it was observed that the rated fire/smoke walls in the basement tele/communications room had penetrations and were not fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1

Based upon observations made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 18.3.4.1. & 9.6.1.4.; and NFPA 72.

This deficiency affected fire alarm control functions.

Findings include:
During the record review made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not inspect/test fire alarm control functions to verify that during an alarm the system will activate the shutdown of required fan control, smoke damper operations and the door holder release in accordance with NFPA 101 19.3.4.4, 9.6.1, 9.6.5, NFPA 72 14.4.2.2, these findings were verified with the facility manager.

Based upon observations made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101, 9.7.5., NFPA 25 5.2.1.1,25 5.2.2.2
This deficiency affected one of several fire sprinklers.

Findings include
1-During the facility tour the sprinkler head in the basement restroom had sheetrock mud and or paint on the body of the head. Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25 5.2.1.1.

K-0511 Based upon observations made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 3 GFIC outlets.

Findings include
1-During the facility tour it was observed that the 2 outlets at the dietary pot and pan wash sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The facility manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the outlet in the mammography room at the sink was not GFIC protected and was observed to be within 6ft of the sink and not GFCI protected. The facility manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3- During the facility tour it was observed that a main electrical service panel in the basement main electrical room that had storage in front of it blocking access to the electrical service panel in accordance with NFPA table 110-26 (a). Service panels are to have a clear working space of 36" maintained in front of them at all times. NFPA 101 19.5.1, 9.1.2., NFPA 70, 110-26 (a)

During the record review made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not inspect or complete the functional testing of the roll up fire door window assemblies in accordance with NFPA 101 19.7.6, 8.3.3.1, NFPA 80 5.2, 5.2.3

This deficiency affected all required testing of roll up fire doors.

Findings include:
1- During the record review made in the presence of the facility manager on 05-02-2022 it was discovered that there was no documentation of the inspection and or testing of the roll up fire door assemblies located in the hospital. NFPA 101 19.7.6, 8.3.3.1, NFPA 80 5.2, 5.2.3 These finding was verified with the facility manager.

During the record review made in the presence of the facility manager on 05-02-2022, it was determined that the facility did not maintain, inspect the facilities emergency generator set in accordance with NFPA 99 6.4.4 and NFPA 110 8.4.2.3.

This deficiency affected 1 of 2 required tests.

Findings include:

1- During the record review the facility failed to provide documentation that the Maintenance of the generator batteries had been conducted for May. Maintenance of Lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted in accordance with NFPA 110 8.3, 8.3.7