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Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on November 28, 2018, at 3:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes:
a. Persons at risk.
b. Types of services provided during an emergency.

Interview with the maintenance director on November 28, 2018, at 3:00 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on November 28, 2018, at 2:30 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes an annual emergency management training and testing for all staff.

Interview with the maintenance director on November 28, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above element.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on November 28, 2018, at 2:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes an initial training on emergency management for individuals providing services (including volunteers).

Interview with the maintenance director on November 28, 2018, at 2:00 p.m., confirmed the Emergency Preparedness Plan did not include the above element.

Based on observation and interview, the facility failed to maintain two-hour fire rated barriers (between health care and non-health care buildings), at one of one fire barrier.

Findings include:

1. Observation on November 26, 2018, at 9:02 a.m., revealed the fire barrier, between MRI and Medical Office Buildings, had an unsealed wire and open hole in the fire wall.

Interview with the maintenance director on November 26, 2018, at 9:02 a.m., confirmed the above fire barrier deficiency.

Based on observation and interview, the facility failed to maintain two-hour fire rated barriers (between health care and non-health care buildings), at one of three building levels.

Findings include:

1. Observation on November 26, 2018, between 10:50 a.m. and 12:30 p.m., revealed the following fire barriers were deficient:
a. (10:50 a.m.) first floor, 1958/2000 connector fire barrier, outside of medical records, had an unsealed penetration above the fire doors (right corner.;
b. (12:30 p.m.) ground floor, cafeteria fire doors, with the 1958 building, lacked positive latching in the frame.

Interview with the maintenance director on November 26, 2018, at 12:30 p.m., confirmed the above fire barrier component deficiencies.

Based on observation and interview, the facility failed to maintain vertical openings at three of five vertical openings.

Findings include:

1. Observation on November 26, 2018, between 10:22 a.m. and 1:25 p.m., revealed the following exit stair tower deficiencies:
a. (10:22 a.m.) first floor, mechanical room stair tower (O. R. stair), door frame lacked a fire label.
b. (12:45 p.m.) ground floor, stair tower near elevator #7, had a large section of drywall removed from the stair tower wall, above the door.
c. (1:25 p.m.) ground floor, stair tower, at the back of the Emergency department, had a bucket of ice melt stored inside the landing.

Interview with the maintenance director on November 26, 2018, at 1:25 p.m., confirmed the above stair tower deficiencies.

Based on observation and interview, the facility failed to maintain hazardous areas in one of three hazardous locations.

Findings include:

1. Observation on November 28, 2018, at 9:50 a.m., revealed the bio-hazard storage room door, was propped open with a roll of plastic bags and plastic bio-hazard containers.

Interview with the maintenance director on November 28, 2018, at 9:50 a.m., confirmed the above hazardous area door lacked positive latching due to unauthorized hold-open devices.

Based on observation and interview, the facility failed to maintain fire sprinkler systems on two of four building levels.

Findings include:

1. Observation on November 26, 2018, between 1:30 p.m. and 1:40 p.m., revealed the following fire sprinkler deficiencies:
a. (1:30 p.m.) first floor, fire sprinkler pipe, above the ceiling tile, at the corridor of back of the Emergency department, stair and entrance doors, had access control wires draped over the pipe.
b. (1:40 p.m.) basement level, tunnel near stair tower, had a drain valve on the sprinkler pipe that did not have an identification label.

Interview with the maintenance director on November 26, 2018, at 1:40 p.m., confirmed the above sprinkler system deficiencies.

Based on observation and interview, the facility failed to maintain smoke barriers at one of seven smoke compartments.

Findings include:

1. Observation on November 26, 2018, at 1:15 p.m., revealed the ground floor, smoke barrier (above doors), at lobby 2002/1984 buildings, had an unsealed green data wire penetration.

Interview with the maintenance director on November 26, 2018, at 1:15 p.m., confirmed the above unsealed penetration in the smoke barrier wall.

Based on observation and interview, the facility failed to maintain designated smoking areas at one of one staff smoking location.

Findings include:

1. Observation on November 26, 2018, at 9:10 a.m., revealed the designated staff smoking location had combustible trash inside the receptacle designed for cigarette butts only.

Interview with the maintenance director on November 26, 2018, at 9:10 a.m., confirmed the combustible trash inside the cigarette butt receptacle.

Based on document review and interview, the facility failed to maintain piped-in medical gas systems for one of one medical gas system.

Findings include:

1. Observation on November 26, 2018, at 1:45 p.m., revealed the last medical gas system testing (October 1-2, 2018), revealed deficiencies, within the inlets/outlets and shut-off valve components. Facility lacked documentation that these deficiencies were corrected.

Interview with the maintenance director on November 26, 2018, at 1:45 p.m., confirmed the facility lacked documentation that the above medical gas deficiencies were corrected.

Based on observation and interview, the facility failed to maintain electrical systems in wet locations for one of one physical therapy location.

Findings include:

1. Observation on November 26, 2018, at 9:20 a.m., revealed the second floor, equipment room, had a hydrocollator plugged into an electrical outlet that is not a ground fault circuit interrupter (GFCI).

Interview with the maintenance director on November 26, 2018, at 9:20 a.m., confirmed the above hydrocollator was not plugged directly into a GFCI electrical receptacle.

Based on observation and interview, the facility failed to maintain electrical power cords on two of four building levels.

Findings include:

1. Observation on November 26, 2018, between 9:15 a.m. and 1:20 p.m., revealed the following areas had misuse of electrical surge protectors:
a. (9:15 a.m.) second floor, training center, room 36, had a surge protector plugged into another surge protector.
b. (1:00 p.m.) ground floor, X-ray reading room, had a surge protector plugged into another surge protector.
c. (1:20 p.m.) ground floor, Women's Health suite reception area, had a refrigerator plugged into a surge protector.

Interview with the maintenance director on November 26, 2018, at 1:20 p.m., confirmed the above locations had misuse of surge protectors.

Based on observation and interview, the facility failed to maintain medical gas systems at one of one main manifold room.

Findings include:

1. Observation on November 26, 2018, at 10:30 a.m., revealed the first floor, main medical gas manifold room, was not constructed, (and did not use interior finishes of noncombustible or limited-combustible materials) such that all walls, floors, ceilings, and doors are of a minimum one-hour fire resistance rating.

Interview with the maintenance director on November 26, 2018, at 10:30 a.m., confirmed the above medical gas room was not one-hour fire rated.