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Based on record review, and interview the facility failed to include within their EP program, the type of services the facility could provide in an emergency, and the facility continuity of operations plan. This deficency affects the entire facility. Findings include:

1. Review of the facility EP program on 7/16/19 at 12:30 p.m., showed, the facility Emergency Preparedness Program lacked information about the type of services that the facility could provide in an emergency, equipment inventory, information about the facility's patient population, and needs specific for the continuity of facility's operations.

2. During an interview on 7/16/19 at 12:34 p.m., staff member B stated there was not specific information in the Emergency Preparedness Program related to information about the patient population the facility serves.

Based on record review and interview, the facility failed to plan and implement a provision of subsistence needs for the staff and the patients. This affects all occupants in the facility. Findings include:

1. Review of the EP plan, policies, and procedures on 7/16/19 at 12:30 p.m., showed the facility lacked a complete system for determining subsistence needs for staff and patients, particularly specific needs for medical and pharmaceuticals.

2. During an interview on 7/16/19 at 12:36 p.m., staff member B stated the facility does not have a policy or procedure regarding medical and pharmaceutical supplies needed during an emergency.

Based on record review and interview, the facility failed to develop a policy and procedure for a means to preserve access, protect residents' confidentiality; and to maintain resident information availability. This affects all of the residents. Findings include:

1. Review of the EP plan policy and procedures on 7/16/19, at 12:30 p.m., showed a lack of a written policy for the retention of the medical documentation that preserved resident information, explaining how the medical information is accessed and secured while its confidentiality is protected. The facility failed to provide a policy and procedure for how medical documentation will be handled during and emergency.

2. During an interview on 7/16/19 at 12:40 p.m., staff member B stated the facility did not have a policy and procedure for medical documentation but they were working on getting one in place.

Based on record review, the facility failed to describe its role under an 1135 waiver during the provision of care and treatment at an alternate site during an evacuation. This deficiency affects the entire facility. Findings include:

1. Review of the facility EP program on 7/16/19, showed the facility's EP plan did not include a policy or procedure for caring of patients at an alternate care site, delineating their role under the 1135 waiver, and showing joint planning on issues related to staffing, equipment and supplies at alternate care sites.

Based on record review, the facility failed to update as needed, an emergency preparedness communication plan including names and contact information. This deficiency has the potential to affect the entire facility. Findings include:

1. Review of the facility EP program on 7/16/19 showed the facility had a policy stating they were going to utilize volunteers in an emergency however the facility's communication plan lacked documentation of contact information for volunteers.

Based on record review and interview the facility failed to develop and implement emergency preparedness (EP) communications plan including contact information for The State Licensing and Certification Agency and the facility's Ombudsman. This deficiency has the potential to affect the entire facility. Findings include:

1. Review of the facility EP plan on 7/16/19 showed the facility's emergency preparedness plan lacked contact information for The State Licensing and Certification Agency and the facility's Ombudsman.

2. During an interview on 7/16/19 at 12:42 p.m., staff member B stated, the facility did not include the contact information for The State Licensing and Certification Agency or the Ombudsman.

Based on observation, the facility failed to maintain 2-hour separation in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 8.3.1.2 and 8.3.3.3. The deficiency affected 2 of 4 main floor smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 12:27 p.m., the two-hour building separation between the clinic and the hospital was inspected. The cross-corridor 2-hour doors by the mail room were exercised. The doors failed to latch under the power of the self-closer.

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5). This deficiency affects 1 of 4 smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 10:25 a.m., the therapy waiting area was inspected. The waiting area was in a marked egress corridor. There was a row of chairs and a sign-in table in the corridor. It reduced the corridor width to less than 6 feet. The furniture was not bolted to the wall or the floor.

Based on observation, the facility failed to ensure exits were free and clear of objects obstructing exits, egress therefrom, or visibility thereof in accordance with NFPA 101, 2012 Edition, Section 7.1.10.2.1. This deficiency affects 3 of 4 main floor smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 11:58 a.m., the 300 hall exit door was inspected. There was a nylon "STOP" sign across the door with velcro attaching it across the threshold of the exit. The exit is a marked exit, the sign across the door may create confusion as to whether or not the exit is functional.

2. During an observation on 7/16/19 at 12:07 p.m., the 200 hall exit door was inspected. There was a nylon "STOP" sign across the door with velcro attaching it across the threshold of the exit. The exit is a marked exit, the sign across the door may create confusion as to whether or not the exit is functional.

3. During an observation on 7/16/19 at 12:22 p.m., the 100 hall exit door was inspected. There was a nylon "STOP" sign across the door with velcro attaching it across the threshold of the exit. The exit is a marked exit, the sign across the door may create confusion as to whether or not the exit is functional.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7. This deficiency affects 1 of 2 basement smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 10:20 a.m., the laudry room storage door was found to have an unapproved hold-open device on the door. Any hold-open device on a hazardous room must be interfaced with the fire alarm system.

2. During an observation on 7/16/19 at 10:52 a.m., there was a door in the maintenance hall which was held open with an unapproved device. The door was a two-hour horizontal exit door.

Based on observation, the facility failed to post exit signage in accordance with NFPA 101-2012, Section 7.10.8.3.1 and 7.10.8.3.2. This deficiency affects 1 of 4 main floor smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 11:46 a.m., the patio door next to the sitting room was inspected. The door was not a marked exit and contained a sign stating "Not a exit." The sign was not clearly readable from a distance, as it did not have the proper font and size of the words.

Based on observations, the facility failed to ensure rooms being used as storage had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. This deficiency affects 2 of 2 basement smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 10:20 a.m., the maintenance shop was inspected. The room is considered a hazardous area and was not fitted with the necessary self-closing device.

2. During an observation on 7/16/19 at 10:54 a.m., the business records storage room was inspected. The room was 82 sq. feet, it was not fitted with the necessary self-closing device.

3. During an observation on 7/16/19 at 11:02 a.m., the clean laudry corridor door was exercised. It would not latch under the power of the self-closing device.

Based on observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7. This deficiency affects 1 of 4 main floor smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 11:47 a.m., the fire alarm pull station near the main entrance was found to be blocked from instant access by a small decorative table.

Based on observation and interview, the facility failed to test the fire alarm system as required per NFPA 72-2010, Section 14.6.2.4. This deficiency affects the entire building.

Findings include:

On 7/16/19, review of the 3/5/19 annual fire alarm system inspection report reflected the contractor did not provide an itemized list with the following information, device type, address, location, and the test result as required for the Intiating and Supervisory devices. The alarm testing records were not specific to each of these devices in this section of the document.

Based on observation and record review, the facility failed to:

a) ensure the sprinkler system was inspected timely on quarterly intervals per NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2.;
b) ensure the inspector's test orifice was installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.17.4.2.1.
c) failed to ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.
d) ensure sprinkler heads were installed at a proper minimum distance from walls, in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.3.3.

These deficiencies affect all smoke compartments.

Findings include:

1. Review of facility sprinkler inspection records on 7/16/19 reflect it was 112 days between inspections for the third and fourth quarter of 2018, on the wet sprinkler system. Inspections are required every 90 days with a 10 day grace period, for a total of 100 days.

2. During an observation on 7/16/19 at 10:27 a.m., the inspector's test valve and outlet was inspected. The valve for the inspector's test appeared to be a 1+ inch valve. The outlet was found to be a 3/4 inch orifice, which is greater than the smallest orifice on the system.

3. During an observation on 7/16/19 at 10:37 a.m., the boiler room was inspected. The sprinkler pipes were found to have external loads placed on them by IT wires attached to the pipe.

4. During an observation on 7/16/19 at 10:48 a.m., the laundry room storage area was inspected. The sprinkler pipes were found to have external loads placed on them by IT wires attached to the pipe.

5. During an observation on 7/16/19 at 10:56 a.m., the maintenance hall was inspected. The sprinkler pipes were found to have external loads placed on them by IT wires attached to the pipe.

6. During an observation on 7/16/19 at 11:03 a.m., the dirty side of the laundry was inspected. The sprinkler pipes were found to have external loads placed on them by IT wires attached to the pipe.

7. During an observation on 7/16/19 at 12:05 p.m., the sprinkler heads in the bathrooms of rooms 208 and 210 were found to be less than four inches from the wall. Four inches in the minimum distance allowed for standard pendant sprinkler heads.

Based on observation, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10-2010, Standard for Portable Fire Extinguishers, Section 6.1.3.4 and 6.1.3.1. This deficiency affects 2 of 2 basement smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 10:24 a.m., a fire extinguisher was left freestanding on a counter in the therapy room. It was not mounted at a proper height on the wall.

2. During an observation on 7/16/19 at 11:00 a.m., the purchasing office was inspected. The portable fire extinguisher in the room was observed to be blocked from immediate access by a pile of boxes, and was mounted higher than five feet to the top of the handle of the extinguisher.

Based on observation, the facility failed to maintain corridor doors and to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5. These deficiencies effect 1 of 4 main floor smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 12:20 p.m., the corridor door to resident room 110 was exercised. The door would not close and latch with a nominal amount of force placed on it.

2. During an observation on 7/16/19 at 12:21 p.m., the corridor door to resident room 108 was exercised. The door would not close and latch with a nominal amount of force placed on it.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. This deficiency affects all smoke compartments.

Findings include:

1. Review of facility documents regarding fire drills for the last year reflected there was no documentation for a completed drill for the day shift of the second quarter of 2018.

Based on observation, the facility failed to keep soiled linen receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1. This deficiency affects 1 of 2 basement smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 10:51 a.m., the maintenance hall was inspected. There were two large (>64 gallons) rolling bins for recycling cardboard in the corridor. The largest size allowed to be unattended in the corridor is 32 gallons.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 8.3.3.1, 19.7.6, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). This deficiency affects all of the fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 7/16/19 reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers in the building and show inspections of all components of the fire doors in those barriers.

Based on observation and interview, the facility failed to utilize portable space heaters in a health care occupancy in accordance with NFPA 101, 2012 Edition, Section 19.7.8. This deficiency affects 1 of 4 main floor smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 11:57 a.m., resident room 308 was inspected. There was a portable space heater in use in the room.

Based on observation, the facility failed to ensure that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 1 of 2 basement smoke compartments.

Findings include:

1. During an observation on 7/16/19 at 10:22 a.m., the therapy room was inspected. There was an unsecured surge protector hanging from the cords that were plugged into it.