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Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for 19(staff C, staff F, staff S, staff U, staff Y, staff Z, staff AA, staff BB, staff CC staff DD, staff EE, staff FF, staff GG staff HH, staff II, staff JJ, staff KK staff LL, and staff MM ) of 22 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for new, existing staff, volunteers and individuals providing services under arrangement for the following staff:

Staff C with the date of hire 06/22/97 did not receive initial in-service training in 1997-2012, and 2015-2016 for the emergency preparedness plan.

Staff F with the date of hire 12/16/02 did not receive initial or annual in-service training in 2002-2013, and 2015-2016 for the emergency preparedness plan.

Staff S with the date of hire 02/13/17, did not receive initial in-service training for the emergency preparedness plan.

Staff U with the date of hire 06/22/97 did not receive initial or annual in-service training in 1997-2013, 2015, for the emergency preparedness plan.

Staff Y with the date of hire 05/22/14, did not receive initial or annual in-service training in 2015 for the emergency preparedness plan.

Staff Z with the date of hire 06/01/15 did not receive initial in-service training for the emergency preparedness plan.

Staff AA with the date of hire 06/22/97 did not receive initial in-service training in 1997-2012, 2015 for the emergency preparedness plan.

Staff BB with the date of hire 08/07/11 did not receive initial in-service training in 2011-2015 for the emergency preparedness plan.

Staff CC with the date of hire 05/11/15 did not receive initial in-service training for emergency preparedness plan.

Staff DD with the date of hire 02/27/06 did not receive initial or annual in-service training in 2006-2012, 2015, and 2018 for the emergency preparedness plan.

Staff EE with the date of hire 09/13/04 did not receive initial or annual in-service training in 2004-2013, 2015 for the emergency preparedness plan.

Staff FF with the date of hire 06/22/97 did not receive initial or annual in-service training 1997-2012, 2015, for emergency preparedness plan.

Staff GG with the date of hire 08/07/11 did not receive initial or annual in-service training 2011-2013, 2015, and 2017-2018 for the emergency preparedness plan.

Staff HH with the date of hire 01/23/16 did not receive initial in-service training for emergency preparedness plan.

Staff II with the date of hire 04/14/14 did not receive annual in-service training in 2015 for the emergency preparedness plan.

Staff JJ with the date of hire 07/30/18 did not receive initial in-service training for the emergency preparedness plan.

Staff KK with the date of hire 12/08/96 did not receive initial or annual in-service training 1996-2012, 2015 for the emergency preparedness plan.

Staff LL with the date of hire 10/29/01 did not receive initial or annual in-service training in 2001-2015, and 2017 for emergency preparedness plan.

Staff MM with the date of hire 06/07/04 did not receive initial or annual in-service training in 2004-2012, 2015 and 2018 for the emergency preparedness plan.

On 01/16/19 at 1:37 pm the surveyor asked Staff E for documentation of training in-service for new, existing staff members, volunteers and individuals providing services under arrangement/contract. Staff E informed surveyor the facilities training system only went back as far as 2006 and she was unable to access and provide training before 2006 because the facility had switched systems and she had no excess to the previous training system. The initial and annual in-service training does not exist for staff C, staff F, staff S, staff U, staff Y, staff Z, staff AA, staff BB, staff CC staff DD, staff EE, staff FF, staff GG staff HH, staff II, staff JJ, staff KK, staff LL, and staff MM.
Staff E stated the facility would work on the employees emergency preparedness in-service training.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016 and 2017, as the documents do not exist.

On 01/16/19 at 1:10 pm Staff I was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016 and 2017. Staff I stated they found out yesterday they were required to do annual generator fuel testing so they contracted with a company to get it done but annual emergency generator fuel quality tests have not been done so the documents do not exist.

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

Findings:

On 01/16/19 at 10:21 am two deadbolts were observed on the A12 Ultrasound corridor door.

On 01/16/19 at 10:22 am one deadbolt and a keyed knob was observed on corridor door A11.

On 01/16/19 at 10:22 am Staff NN was asked why there were two deadbolts or two locks on the corridor doors. Staff NN stated he did not know but can take the deadlocks off of each door. The surveyor explained to Staff NN it would take more than one action for a person to gain access to the exit egress corridor from inside each of the two areas and to meet compliance it should take only one action to gain exit egress access.

On 01/17/19 at 11:25 am two deadbolts were observed to be on the C4 Kitchen corridor door.

On 01/17/19 at 12:24 pm on deadbolt was observed on corridor door D2 and on the door to central supply.

On 01/17/19 at 12:29 pm one barrel latch was observed on the medical records door.

On 01/17/19 at 12:30 am Staff NN stated he would take care of the deadbolts and barrel latch.

Based on observation and interview the facility failed to ensure an exit corridor and facility exit discharges were provided with emergency powered lighting.

Findings:

On 01/17/19 at 10:52 am the surveyor observed regular lighting fixtures in the corridor leading from the CT scanner to two exit discharges.

On 01/17/19 at 10:52 am the surveyor asked Staff NN if the existing light fixtures were on emergency powered battery backed up lighting or powered by the emergency generator in the even of the loss of normal electrical power. Staff NN stated he did not believe the lights were on emergency power and were only on normal power. The surveyor stated the lights in the emergency egress corridor leading from the CT scanner to the emergency exit discharge should have either emergency battery backed up power or be wired to the emergency generator in the event of the loss of normal electrical power.

On 01/17/19 at 10:55 am the surveyor observed the exit discharge from the CT area to not have installed emergency lighting. The surveyor stated to Staff NN to meet compliance each facility exit discharge must have emergency powered lighting at each exit discharge. Staff NN stated they understood.

Based on observation and interview the facility failed to ensure hazardous areas are properly protected from other use spaces.

Findings:

On 01/16/19 at 2:44 pm the surveyor observed a non-smoke tight ceiling in the IT area with tiles out of place.

On 01/19/19 at 2:44 pm Staff NN stated they would replace the tile.

On 01/16/19 at 3:04 pm observed three large combustible corrugated boxes filled with combustible nylon lunch boxes stored in IT closet in the physical therapy housekeeping closet.

On 01/16/19 at 3:04 pm the surveyor stated nothing combustible is to be stored in mechanical, IT, communication, or electrical closets in order to be in code compliance. Staff NN stated they would find another place for the boxes.

On 01/16/19 at 3:13 pm the dinning room supply closet was observed to have one missing ceiling tile and was not smoke tight as required. The missing ceiling tile would allow fire and smoke to spread into the attic space and further spread throughout the facility. Staff NN stated they would replace missing ceiling tiles and make sure ceiling tiles are in place.

On 01/17/19 at 1:50 pm the smoke barrier located directly across from the nurses station was observed to have four penetrations.

On 01/17/19 at 1:52 pm the two hour fire wall barrier separating the clinic from the hospital was observed to have four penetrations.

On 01/17/19 at 1:53 pm Staff NN stated the penetrations would be filled with appropriate fire resistant material.

Based on observation and interview the facility failed to ensure corridor doors were equipped with proper hold open devices and roller latches were not used.

Findings:

On 01/16/19 at 10:21 am one rollerlatch was observed on the A12 Ultrasound corridor door.

On 01/16/19 at 10:22 am one rollerlatch was observed on corridor door A11.

On 01/16/19 at 10:22 am Surveyor stated CMS prohibited roller latches by regulation. Staff NN stated he did not know but will take care of the doors that have them.

On 01/17/19 at 11:37 am the surveyor observed a non-complaint metal door stop device installed on the bottom edge of corridor door C5 to X-Ray being held open by the non-compliant metal door stop device. In the event of a fire the corridor door would not automatically close as required.

Based on observation and interview the facility failed to ensure electrical equipment brought into the facility was properly inspected prior to being placed into service and electrical wiring/equipment complies with NFPA 70 as required.

Findings:

On 01/16/19 at 2:32 pm the survyeor observed three extension cords in use within the facility.

On 01/16/19 at 2:32 pm surveyor stated to Staff NN CMS directs health care occupancies not to use extension cords as temporary wiring and should not be used as a replacement in lieu of permanent fixed wiring. Staff NN stated they would take care of the extension cords.

On 01/16/19 at 2:52 pm a refrigerator containing patient food items located next to room B-3 was observed without an inspection sticker.

On 01/16/19 at 2:52 pm the surveyor asked the plant engineer to describe their biomedical inspection program. Staff NN stated they have their biomed vendor come out and do their checks then place stickers on each electrical device. The sticker shows the dates the device current inspection expires. The surveyor asked why the patient food refrigerator did not have a sticker and Staff NN stated the bio med staff must have missed it.

On 01/16/19 at 3:07 pm the surveyor observed hydrocollator plugged into a non-GFCI electrical receptacle. The surveyor stated to Staff NN hydrocollator are required to be plugged into GFCI electrical receptacles.

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 fire drills for 2017 did not document the transmission of a fire alarm signal. The documentation of verification of a fire alarm signal for each fire drill did not exist.

On 01/18/19 at 9:20 am the surveyor stated to Staff NN the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff NN stated they would pass onto staff to be sure and add transmission of a fire alarm signal to each fire drill document.

Based on observation and interview the facility failed to ensure soiled linen/trash containers exceeding 32 gallons in capacity were stored in a protected hazardous area when not attended.

Findings:

On 01/16/19 at 03:02 pm a combustible plastic barrel container exceeding 32 gallons with soiled linen was observed stored open to the egress corridor within the physical therapy closet in the physical therapy department.

On 01/16/19 at 03:02 pm the surveyor stated any container over 32 gallons needs to be store in a one hour fire rated protected area to meet compliance. Staff NN state they will correct it.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 were not completed and the documentation did not exist.

On 01/16/19 at 12:35 pm the surveyor asked Staff NN for the annual fire rated door assembly inspections. Staff NN stated the inspection was not completed for 2017 and the documentation did not exist.

Based on observation and interview, the facility failed to ensure space heaters were not placed in patient care areas as required.

Findings:

On 01/16/19 at 2:34 pm two space heaters were observed in the administrative office.

On 01/16/19 at 2:38 pm three space heaters were observed in staff offices.

On 01/17/19 at 11:57 am one space heater was observed in the physicians assistant sleeping room.

On 01/16/19 at 2:24 pm Staff NN was asked for the manufacturers documentation that the heating element in the space heaters did not exceed 212 degrees Fahrenheit for the space heaters located in the facility. Staff NN stated they did not readily have the manufacturers documentation. The surveyor stated to Staff NN the documentation may be obtained from the manufactuers website. Staff NN was informed of CMS's standard regarding space heaters in which are prohibited in all health care occupancies within patient care areas, but can only be utilized in nonsleeping staff employee areas.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.

On 01/17/19 at 11:23 am during record review the surveyor asked Staff NN for the EES and Medical Gas building system risk assessments, and Staff NN stated he had not completed the medical gas or EES building system risk assessments.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016 and 2017, as the documents do not exist.

On 01/16/19 at 1:10 pm Staff I was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016 and 2017. Staff I stated they found out yesterday they were required to do annual generator fuel testing so they contracted with a company to get it done but annual emergency generator fuel quality tests have not been done so the documents do not exist.