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Based on observation and interview the facility failed to ensure the provision of the subsistence needs for staff and patients in the event of a emergency event/disaster.

Findings:

On 11/18/19 at 2:15pm the surveyor observed in the facility there was no pre-identified or outlined provision of the subsistence need for staff and patients whether they were to evacuate or shelter in place, which included but not limited to food, water, and pharmaceutical supplies.

On 11/18/19 the surveyor asked staff D if the facility emergency operations plan included the subsistence need for staff and patients whether they were to evacuate or shelter in place. Staff D stated they are still developing their emergency plan and will add the provision of emergency food to it.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.

On 11/18/19 at 10:50 am, the surveyor asked Staff D if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff D stated the facility is in process of updating policies to ensure compliance. The document did not exist.

Based on record review and interview the facility failed to ensure development and implementation of an emergency preparedness communication plan which complies with Federal, State, local laws to be reviewed/updated at least annually.

Findings:

Record review showed the facility did not have a emergency preparedness communication plan which complies with Federal, State, and local laws. It did not exist.

On 11/19/19 at 11:33 am staff D was asked for the facility emergency preparedness communication plan. Staff D stated they did not have a communication plan but will get it included with the required components.

Based on record review and interview the facility failed to ensure their emergency preparedness training and testing curriculum was reviewed/updated at least annually.

Findings:

Record review showed the facility's emergency preparedness testing and training programs were not reviewed/updated at least annually as required.

On 11/18/19 at 11:40 am Staff D was asked for documentation verifying the facility emergency preparedness training and testing materials have been reviewed/updated at least annually. Staff D provided the emergency preparedness plan which was dated 03/17 and did not include EP curriculum or EP testing materials. Staff D stated they have not reviewed or updated the emergency training or testing curriculum.

Based on observation and interview, the facility failed to ensure each egress access door could be opened with only one action as required.

Findings:

On 11/18/19 at 12:07 pm a deadbolt lock was observed on the physical therapy office emergency egress access corridor door.

On 11/18/19 at 12:08 pm Staff B was asked why the deadbolt lock was placed on the physical therapy office emergency egress access corridor door. Staff B stated it may have been due to security issues but they will remove it to meet compliance.

Based on observation and staff interview the facility failed to ensure emergency powered illumination of the means of egress in accordance with Chapter 7.8, Chapter 21.2.8 to be either continuously in operation or capable of automatic operation without manual intervention as required.

Findings:

On 11/18/19 at 3:33 pm while on tour of the facility, exit discharge lighting could not be observed or identified at each of the facility's exit discharges areas.

On 11/18/19 at 3:35 pm the surveyor asked staff B if they knew the existing lighting fixtures which were observed to be turned on with normal electrical power were electrically wired to the emergency generator. Staff B stated they did not know and did not believe so. Staff B stated he could not confirm which lights in the facility were on emergency generator power.

Based on observation and interview the facility failed to ensure hazardous areas were protected as required.

Findings:

On 11/18/19 at 11:54 am the surveyor observed three combustible plastic items, (plastic floor fans) stored within the hazardous area electrical closet.

On 11/18/19 at 11:55 am the surveyor asked staff B why the three combustible plastic floor fans were stored within the electrical closet. Staff B stated they were not aware but will remove the three plastic floor fans.

Based on observation and interview the facility failed to ensure cooking equipment was protected in accordance with NFPA 96 as required.

Findings:

Record review showed the facility had not had the kitchen hood cleaned every six months in 2019 and 2018 as required. The documentation did not exist.

On 11/18/19 at 2:43 pm surveyor asked staff B for the hood cleaning logs for the last three years. Staff B stated they will have the corporate dietitian find the paperwork. Staff B stated they could not find the documentation.

Based on record review, and interview the facility failed to ensure the fire alarm system was monitored as required.

Findings:

Record review showed the facility fire alarm system is not being monitored and has not been for several months per the SAF vendor report dated 07/31/19.

On 11/15/19 at 2:17 pm the surveyor asked staff B why the fire alarm system was yellow tag by SAF their fire alarm system inspection vendor. Staff B stated their fire alarm vendor SAF found their system was not being monitored as required. Staff B stated since the facility was going into bankruptcy they did not have the money to correct it.

Based on observation and interview the facility failed to ensure smoke detectors were installed properly as required.

Findings:

On 11/18/19 at 3:48 pm the surveyor observed a smoke detector sitting on a wooden beam one foot below the ceiling. The surveyor asked staff B why the smoke detector was placed on the wooden beam one foot below the ceiling instead of being installed on the ceiling. Staff B stated they did not know. The surveyor explained that smoke would accumulate until it reached one foot down from the ceiling then it would set off the smoke alarm rather than the smoke alarm being installed on the ceiling which would give earlier warning/detection.

Based on observation and interview the facility failed to ensure corridor doors did not have roller latches installed.

Findings:

On 11/18/19 at 2:45 pm the surveyor observed a barrel latch on a corridor door and the asked staff B why it was installed. Staff B stated they installed it because of the imaging device that is in the room. The surveyor stated barrel latches are prohibited and in addition no second locking device should be placed on an emergency egress corridor door. Staff B stated they would remove the barrel latch.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 11/15/19 at 3:54 pm the surveyor stated to Staff B the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff B stated they would add that to the fire drill documentation.

Based on record review and interview the facility failed to ensure the facility medical gas and vacuum systems were inspected/maintained as required.

Findings:

Record review showed the facility has had an annual inspection of the medical gas and vacuum systems for 2018 and 2017.

On 11/15/19 at 2:07 pm the surveyor asked staff B when the last annual medical gas and vacuum systems was completed. Staff B stated there were portions of the medical gas systems that was replaced several years ago and their medical gas vendor did that. The surveyor explained that any repair or replacement is not the same as a annual certification of the medical gas systems. Staff B stated the bulk oxygen tank was inspected by Matheson 8-30-19, but nothing else was.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data as required.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles as required.

On 11/18/19 at 11:27 am the surveyor asked staff B why the impedance testing has not been completed. Staff B stated he was not totally familiar with all of the requirements for life safety code since he just recently started in his position but will get the testing scheduled to be done with their electrical contractor.

Based on record review, observation and interview the facility failed to ensure their Type 1 EES was separated into a life safety, critical, and equipment branch panel and had a letter of reliability from the natural gas provider as required.

Findings:

Record review showed the facility did not have a letter of reliability from their natural gas vender who supplies gas to their emergency generator.

On 11/15/19 at 1:10 pm the surveyor asked staff B if their emergency generator is natural gas, or diesel powered. Staff B stated they have a natural gas powered emergency generator. The surveyor explained CMS requires the facility to have this letter of reliability from their natural gas vendor containing a statement of reasonable reliability of the natural gas delivery, a brief description that supports the statement regarding the reliability, a statement that there is a low probability of interruption of the natural gas, a brief description that supports the statement regarding the low probability of interruption, a signature of technical personnel from the natural gas vendor.

On 11/18/19 at 4:30 pm the surveyor observed a single electrical branch panel feeding off from the emergency generator and the circuit breakers within the electrical panel box were not labeled as required. There was no life safety, critical and equipment branch panel identified or labeled. Only one branch panel was observed and it was not labeled or identified.

On 11/18/19 at 4:38 pm the surveyor asked staff B if there were any other panels other than the one and staff B stated it is the only one they are aware of. The surveyor explained hospitals are required to have a Type 1 EES emergency generator which requires a life safety branch panel, critical branch panel and other equipment branch panel leading off from the facility's emergency generator.

Based on observation and interview the facility failed to ensure extension cords were not used as a substitute for fixed wiring of a structure.

Findings:

On 11/18/19 at 12:17 pm the surveyor observed an extension cord pulled into an emergency electrical receptacle near emergency room patient bed number two.

On 11/18/19 at 12:17 pm the surveyor asked staff A why the extension cord was there. Staff A stated it was to power a computer in the emergency room reception area next door but they will get it removed.

On 11/18/19 at 12:18 pm the surveyor observed a multiplug with a power strip daisy chained into it in use in the emergency room reception area.

On 11/18/19 at 12:18 pm the surveyor asked staff A why they had a multiplug in use. Staff A stated they must not have had enough electrical outlets.