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Based on record review, and interview the facility failed to develop, establish, and maintain a comprehensive emergency preparedness (EP) program that identifies all-hazards approach strategies for addressing the facility's vulnerability during emergency events. This affects all staff and residents of the facility. Findings include:

1. Review of the facility EP program on 8/6/19, showed there was no documentation of a facility-based, or community-based risk assessment.

2. During an interview on 8/6/19 at 4:02 p.m., staff member B stated the risk assessments addressing the facility's vulnerabilities could not be found.

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 8/6/19 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 8/6/19, at 4:03 p.m., staff member B stated he was not sure if there was 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 include a process for collaboration with local officials regarding the facility's emergency preparedness program. The deficiency affects all patients and staff in the facility. Findings Include:

1. Review of the EP plan on 8/6/19 showed, the facility's EP plan lacked a written documentation of how the facility was integrating its emergency preparedness program into local city, and/or county, and state programs and contacting such officials for current and future collaborative and cooperative planning efforts.

2. During an interview on 8/6/19 at 4:06 p.m., staff member B stated he did not see anything in the EP plan related to a collaberation with local officials.

Based on record review the facility failed to update, implement, and annually review emergency preparedness (EP) policies and procedures. This deficiency has the potential to affect all patients and staff of the facility. Findings include:

1. A review of the facility EP program on 8/6/19 showed, the facility's EP programs policies and procedures were not based on the facilities vulnrabilities due to the facility not completing a risk asessment.

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

1. Review of the EP plan, policies, and procedures on 8/6/19 showed, the facility lacked a complete system for determining subsistence needs for staff and patients, particularly specific needs for food, medical and pharmaceuticals, and sewage and waste disposal.

Based on record review the facility failed to develop a system to track the location and availability of on-duty staff, volunteers, and patients during an emergency. The deficiency affects all staff, residents, and volunteers in the facility. Findings Include:

1. Review of the facility EP program on 8/6/19 showed, the facility EP plan lacked supporting documentation that the facility had established a system to track on-duty staff, volunteers, and residents during an emergency.

Based on record review the facility failed to develop and implement emergency preparedness (EP) policies and procedures addressing safe evacuation, including staff responsibilities and needs of the patients. Findings include:

1. Review of the EP plan on 8/6/19 showed the plan did not contain specific procedures regarding evacuation of residents or staff. there was no information regarding tracking residents and their corresponding needs regarding care.

Based on record review the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers. This affects all of the patients at the facility. Findings include:

1. Review of the facility EP program on 8/6/19 showed, the plan lacked information about the use of volunteers during an emergency.

Based on record review the facility failed to ensure the EP plan contained current agreements/arrangements with other facilities and/or other providers to receive residents in the event of an evacuation and/or cessation of operation. This affects all the occupants in the facility. Findings include:

1. Review of the EP plan on 8/6/19 showed, a lack of written agreements with other providers in the event of limitations to provide needed services to the residents to maintain the continuity of services.

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 8/6/19 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. This deficiency has the potential to affect the entire facility. Findings include:

1. Review of the facility EP program on 8/6/19 showed, the facility's communication plan lacked documentation of contact information for entities providing services including paitents physicians, and staff.

Based on record review, the facility failed to develop and implement emergency preparedness (EP) communications plan including contact information for The State Licensing and Certification Agency. Findings include:

1. Review of the facility EP plan on 8/6/19 showed, the facility's emergency preparedness plan lacked contact information for The State Licensing and Certification Agency.

Based on record review the facility did not develop a written policy for an incident command center for communications of its occupancy needs as well as its ability to provide assistance in a case of an emergency. This deficiency affects all residents in the facility. Findings include:

1. Review of the facility's EP plan on 8/6/19 showed, a lack of policy and procedures for specific means of communicating with the authority having jurisdiction about the incident, the command center for all communications in regards to its occupancy needs and/or its ability to provide assistance in a case of a disaster situation.

Based on record review the facility failed to develop and maintain an EP training and testing program that is based on the facility's Emergency Preparedness plan. This deficiency has the potential to affect all staff, volunteers, and residents of the facility. Findings include:

1. Review of the facility EP plan on 8/6/19 showed, the facility EP plan lacked documentation of testing and training on the facility EP plan for staff, volunteers or residents.

Based on record review the facility failed to implement the annual training of the EP program to all staff members, consistent with each team members' expected roles during an emergency or a disaster. This deficiency affects all of the occupants and staff in the facility. Findings include:

1. Record review of the facility EP plan and training documents on 8/6/19 showed, the facility failed to show evidence that staff training for the EP plan was conducted initally for new staff and annually for all current staff.

Based on record review the facility failed to conduct any full-scale community-based (or a full-scale facility based) exercise, at least annually This deficiency affects all staff and patients in the facility. Findings include:

1. Review of the facility EP plan on 8/6/19 showed a lack of evidence that the facility had conducted a full-scale community-based and/or facility-based exercise in the last year.

Based on observation, the facility failed to ensure the fire and smoke resistance rating of ceiling assemblies in a building was maintained in accordance with NFPA 101-2012, Section 19.1.6.2 and failed to maintain the 2-hour fire rated barrier in accordance with NFPA 101-2012, Sections 19.1.3.5 and 8.2.1.3.

Findings include:

1. During an observation on 8/6/19 at 10:12 a.m., the two-hour fire door leading to the service hall way from extended care would not close and positively latch when exercised.

2. During an observation on 8/6/19 at 12:22 p.m., there were ceiling tile penetrations observed in the IT server room.

3. During an observation on 8/6/19 at 12:39 p.m., the lab storage room was inspected. Two ceiling tiles were removed from the ceiling within the room.

4. During an observation on 8/6/19 at 12:54 p.m., the ambulance entrance office was inspected. Two ceiling tiles were removed from the ceiling within the room.

5. During an observation on 8/6/19 at 1:50 p.m., there was a penetration in the ceiling tile located in the entrance to PT.

6. During an observation on 8/6/19 at 2:06 p.m., the D wing two-hour fire doors would not close and positively latch when exercised.

Based on observation, the facility failed to ensure the fire and smoke resistance rating of ceiling assemblies was maintained in accordance with NFPA 101-2012, Section 19.1.6.2. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 9:42 a.m., the Family Practice office was inspected. A ceiling tile was observed to be removed in suite 114.

2. During an observation on 8/6/19 at 9:31 a.m., two ceiling tiles were removed in the main hall of the medical clinic.

Based on observation, 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 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 10:37 a.m., there was storage on both sides of the service hall way reducing the means of egress to less than five feet.

2. During an observation on 8/6/19 at 10:38 a.m., the means of egress was blocked by a garbage can, located at the kitchen door.

3. During an observation on 8/6/19 at 10:41 a.m., the means of egress was blocked by a cart being stored in front of the kitchen emergency exit door.

Based on observation, 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 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 2:14 p.m., the means of egress was blocked in the materials storage room, by various items being stored in the path leading to the exit door within the room.

Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5., 10.2. These deficiencies affect 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 12:57 p.m., the emergency department ultrasound room was inspected. A door with a lock that required more than one releasing operation was observed on the door within the room.

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.

Findings include:

1. During an observation at 8/6/19 at 3:28 p.m., the weight room door had a door stop holding it open, preventing it from closing and latching during a fire.

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.

Findings include:

1. During an observation on 8/6/19 at 12:05 p.m., the gift shop door had a door stop holding it open, preventing it from closing and latching during a fire.

2. During an observation on 8/6/19 at 12:15 p.m., the pharmacy was inspected. The door leading to the corridor from pharmacy would not positively latch and close when exercised. The door was fitted with a self-closure.

3. During an observation on 8/6/19 at 12:56 p.m., the ER ultrasound room had a door stop holding it open, preventing it from closing and latching during a fire.

4. During an observation on 8/6/19 at 1:59 p.m., the door to the soiled linen and clean linen rooms would not self-close and positively latch when exercised. The doors were fitted with self-closures.

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.

Findings include:

1. During an observation on 8/6/19 at 2:17 p.m., the generator room had a door stop holding it open, preventing it from closing and latching during a fire.

2. During an observation on 8/6/19 at 3:26 p.m., the record storage basement door was inspected. The door leading to the corridor from the room would not positively latch and close when exercised. The door was fitted with a self-closure.

3. During an observation on 8/6/19 at 3:28 p.m., the water room door was inspected. The door leading to the corridor from the room would not positively latch and close when exercised. The door was fitted with a self-closure.

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.

Findings include:

1. During an observation on 8/6/19 at 9:49 a.m., the door to the main clinic was inspected. The door was fitted with a self-closure and would not close and positively latch when exercised.

Based on observation, the facility failed to prevent the use of enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3. This deficiency affects 1 basement smoke compartment.

Findings include:

1. During an observation on 8/6/19 at 3:08 p.m., a broom, garbage can, and other miscellaneous items were observed being stored in the stairwell leading from the basement to the outside of the building.

Based on observation, the facility failed to ensure accessibility to a manual fire alarm pull station in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 12:44 p.m., the fire alarm pull station near the main entrance of the ER was found to be blocked from instant access by wheel chairs being stored in front of it.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures and were not missing escutcheon rings in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 8/6/19 at 10:35 a.m., a sprinkler head was missing an escutcheon ring, located in the service hallway.

2. During an observation on 8/6/19 at 10:53 a.m., two sprinkler heads were obstructed by a light, located in the computer lab.

3. During an observation on 8/6/19 at 12:24 p.m., two sprinkler heads were obstructed by a light, located in the Senior Executive Physician Services office.

4. During an observation on 8/6/19 at 12:25 p.m., a sprinkler head was obstructed by a light, located in the closet of the Administration office.

5. During an observation on 8/6/19 at 1:06 p.m., a sprinkler head was missing an escutcheon ring, located in the supply room.

6. During an observation on 8/6/19 at 1:07 p.m., a sprinkler head was missing an escutcheon ring, located in the radiology room.

7. During an observation on 8/6/19 at 1:10 p.m., a sprinkler head was obstructed by a light and four escutcheon rings had fallen off sprinkler heads, located in the Patients Accounts office.

8. During an observation on 8/6/19 at 1:36 p.m., a sprinkler head was missing an escutcheon ring, located in the B room hallway.

9. During an observation on 8/6/19 at 1:39 p.m., a sprinkler head was obstructed by a light, located in the OB nursery hallway.

10. During an observation on 8/6/19 at 1:44 p.m., a sprinkler head was missing an escutcheon ring, located in the Finance/Accounting office.

11. During an observation on 8/6/19 at 1:47 p.m., five sprinkler heads were obstructed in the OB supply room, hallway, and room 301.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures and were not missing escutcheon rings in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 8/6/19 at 9:38 a.m., the ortho waiting room was inspected. A sprinkler head was observed, missing its escutcheon ring.

2. During an observation on 8/6/19 at 9:40 a.m., the ortho nursing station was inspected. A sprinkler head was observed, missing its escutcheon ring.

3. During an observation on 8/6/19 at 9:41 a.m., the exam room 1 in the ortho office was inspected. A sprinkler head was observed, missing its escutcheon ring.

4. During an observation on 8/6/19 at 9:43 a.m., two sprinkler heads were obstructed by a light in the ortho reception office.

5. During an observation on 8/6/19 at 9:59 a.m., a sprinkler head was missing an escutcheon ring, located in suite 101 supply room of the ENT office.

Based on observation and record review, the facility failed to maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

These deficiencies affect the entire building.

Findings include:

1. Review of facility documentation, and observation, reflected the five-year internal inspection and calibration/replacement of the standpipe gauges had not taken place on time. The last time this was completed was in June of 2014.

2. During an observation on 8/6/19 at 10:03 a.m., cords were observed resting on sprinkler piping in the clinic main hall.

Based on observation and record review, the facility failed to maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

These deficiencies affect the entire building.

Findings include:

1. Review of facility documentation, and observation, reflected the five-year internal inspection and calibration/replacement of the standpipe gauges had not taken place on time. The last time this was completed was in June of 2014.

2. During an observation on 8/6/19 at 10:47 a.m., the freezer sprinkler bulb was observed to be empty and did not contain a green fluid.

Based on observation and record review, the facility failed to maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

These deficiencies affect the entire building.

Findings include:

1. Review of facility documentation, and observation, reflected the five-year internal inspection and calibration/replacement of the standpipe gauges had not taken place on time. The last time this was completed was in June of 2014.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. This deficiency affects 1 compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 3:27 p.m., a portable fire extinguisher was blocked, located in the record storage room.

2. During an observation on 8/6/19 at 3:46 p.m., a portable fire extinguisher was blocked, located in the elevator room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/18 at 10:53 a.m., a portable fire extinguisher was obstructed in the computer lab.

2. During an observation on 8/6/19 at 12:37 p.m., a portable fire extinguisher was obstructed in the lab.

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 affect 1 smoke compartments in the building.

Findings include:

1. During an observation on 8/6/19 at 1:29 p.m., resident room 214 was inspected. The door to would not close and positively latch when exercised.

Based on an observation and interview, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B). The deficiency affects one smoke compartment in the building.

Findings include:

1. During an observation on 08/06/19 at 12:55 p.m., the ambulance entrance office was inspected. Exposed wires were observed protruding from the wall.

During an interview on 08/06/19 at 12:56 p.m., staff member A stated the opening in the wall was where a clock used to be. He stated the exposed wires needed to be covered with an electrical plate.

Based on an observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B). The deficiency affects one smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 2:09 p.m., D wing stairwell to the boiler room was inspected. Electrical wires were observed, protruding out of the wall in the hallway.

Based on observation the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8 and failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1. The deficiencies affect the entire building.

Findings include:

1. Review of the emergency generator inspection records on 8/6/19, showed the annual diesel fuel supply quality test was not conducted within the last year.

2. During an observation on 8/6/19 the generator was inspected. The generator lacked a labeled manual stop station at a remote location outside of the room housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to keep the room housing the Emergency Power Supply System (EPSS) free from any other equipment per NFPA 110 2010 Edition, Section 7.2.1.2. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 2:16 p.m., the generator room was inspected. Multiple items were observed, being stored within the room.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation at 8/6/19 at 3:28 p.m., the fitness center was inspected. Three extension cords were observed in use and plugged into the wall.

2. During an observation on 8/6/19 at 3:38 p.m., the track room was inspected. A blue extension cord was observed in use and plugged into the wall.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 3:26 p.m., the basement was inspected. An extension cord was observed in use and was plugged into a fan.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 9:25 a.m., the medical clinic was inspected. A brown extension cord was found plugged into the wall and in use, in the Family Practice office.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 3 smoke compartments in the building.

Findings include:

1 During an observation on 8/6/19 at 12:37 p.m., the lab was inspected. A surge protector was observed unsecured and dangling from the wall.

2. During an observation on 8/6/19 at 12:58 p.m., the mamo station was inspected. A surge protector was observed unsecured and dangling from the wall.

3. During an observation on 8/6/19 at 1:08 p.m., the x-ray workroom was inspected. A surge protector was observed unsecured and dangling from the wall.

4. During an observation at 8/6/19 at 1:19 p.m., the A-wing nursing station was inspected. A surge protector was observed unsecured and dangling from the wall.

Based on observation the facility failed to maintain oxygen cylinders per NFPA 99-2012, Section 11.6.2.3. The deficiency affects 1 smoke compartment in the building.

Findings include:

1. During an observation on 8/6/19 at 9:45 a.m., the reception area of the clinic was inspected. An unsecured e-tank was observed sitting on the floor in the room.