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Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73).

Findings include, but are not limited to:
On 6/19/19, during record review between 2:37 pm and 4:45 pm, the facility failed to provide to this surveyor evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (1)(i) defined policies and/or protocols supporting medical, and pharmaceutical supplies for staff, and (D) sewage and/or waste disposal capable of supporting the length of time the facility has chosen to shelter-in-place, as identified within the facility's EP plan.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483).

Findings include, but are not limited to:
On 6/19/19, during record review between 2:37 pm and 4:45 pm, the facility failed to provide evidence to this surveyor of its defined role under a waiver declared by the Secretary, in accordance with section 1135 of the Stafford Act, in the provision of care and treatment at its facility, or an alternate care site, as identified by emergency management officials.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(c)(2)).

Findings include, but are not limited to:
On 6/19/19, during record review between 2:37 pm and 4:45 pm, the facility failed to produce the required contact information for local, tribal, regional, state, and federal EP supportive agencies within their established comprehensive EP Communications Plan.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(c)(3)).

Findings include, but are not limited to:
On 6/19/19, during record review between 2:37 pm and 4:45 pm, the facility failed to properly define primary and secondary means of communication with federal, state, regional, and local emergency preparedness supportive agencies within the EP plan.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483).

Findings include, but are not limited to:
On 6/19/19, during record review between 2:37 pm and 4:45 pm, the facility failed to provide a documented process, policy, or procedure outlining an Emergency Preparedness Training and Testing Program based on the established Emergency Plan that is reviewed and updated annually.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.73(d)(1)).

Findings include, but are not limited to:
On 6/19/19, during record review between 2:37 pm and 4:45 pm, the facility failed to document and communicate the necessary training and testing to include, (ii) external sources providing services under agreement, consistent with their expected roles within the EP plan, based on defined all-hazards scenarios.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to provide proper separation (1-hr. enclosure or automatic extinguishing system) between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 20/21.3.2, 38/39.3.2, and 8.7).

Findings include, but are not limited to:
1. On 6/2019, at 10:40 am, a rated door to the Medical Files Room did not have an auto-closure device installed and the room was greater than 10 ft2.
2. On 6/2019, at 11:00 am, a rated door to the PT Storage Room did not have an auto-closure device installed and the room was greater than 10 ft2.
3. On 6/20/19, at 11:30 am, a rated door to the Medical Files Room in the old LTC section did not have an auto-closure device installed and the room was greater than 10 ft2.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to ensure that piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 , LSC 8.7, 20/21.3.2.3 and S&C 13-58 LSC and S&C 15-27 LSC) This resulted in the potential for injury to patients during medical procedures.

Findings include, but are not limited to:
On 6/20/19, during record review between 9:00 am and 10:09 am, the facility failed to produce a humidity policy to the survey team and there were instances of logged humidity under 30%.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 20/21.3.5, 38/39.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 13, NFPA 25).

Findings include, but are not limited to:
On 6/20/19, at 8:30am, a knock-off cap was found missing on the fire department connection located at the NE corner of the Clinic 2 Building, and the sprinkler riser room was missed labeled as 'FDC.'

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to maintain minimum smoke barrier fire resistance ratings in universe smoke compartments throughout the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 20/21.3.7.3, 20/21.3.7.6, 8.3).

Findings include, but are not limited to:
On 6/20/19, during record review between 9:00 am and 10:09 am, there were multiple smoke and fire dampers throughout the facility and documentation could not be presented to the survey team showing any testing and maintenance.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 20/21.7.1., 20/21.7.2, 20/21.7.2.2, 20/21.7.2.3).

Findings include, but are not limited to:
On 6/20/19, during record review between 9:00 am and 10:09 am, facility documentation presented to the survey team showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as, the number of simulated occupants evacuated from the affected smoke compartment, and time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment.

Surveyors were accompanied by the Facility Administrator, Maintenance Director and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to maintain approved fire-rated doors within the building. This resulted in the potential for the spread of fire/smoke to other compartments (LSC 20/21 and 8).

Findings include, but are not limited to:
1. On 6/20/19, at 10:18 am, a rated fire door from the lobby hallway to the clinic building failed to close and latch properly.
2. On 6/20/19, at 10:32 am, a rated fire door from the Graham Clinic to Doctor's Clinic failed to close and latch properly.
3. On 6/20/19, at 12:59 pm, a rated fire door to the old dining room failed to close and latch properly.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant the facility failed to maintain at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. This resulted in the potential for injury or damage to equipment or possible injury to staff or patients.

Findings include, but are not limited to:
On 6/20/19, during record review between 9:00 am and 10:09 am, the facility failed to produce evidence of the required annual receptacle retention testing.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director and Plant Administrative Assistant that the facility failed to provide safe storage for compressed gas. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 21.3.2, 38.3.2, NFPA 99).

Findings include, but are not limited to:
1. On 6/20/19, at 10:18 am, the facility failed to affix proper NFPA 99 compliant compressed gases signage to the Oxygen storage room door.
2. On 6/20/19, at 11:29 am, the facility was storing combustibles in the oxygen storage room within 5 feet of oxygen cylinders.

Surveyors were accompanied by the Facility Administrator, Maintenance Director, and Plant Administrative Assistant who acknowledged the existence of these findings.