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Based on record review and interview the facility failed to ensure initial in-service training for staff, volunteers and individuals providing services under arrangement, on the emergency preparedness plan for three (staff 3, Staff 5, and staff 8) of 10 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the in-service training for existing staff, volunteers and individuals providing services under arrangement. Staff 3 who worked as a Registered Nurse with the date of hire 11/27/17, had not received initial in-service training for emergency preparedness, Staff 5 who worked as a cook with the date of hire 10/09/03 had not received initial in-service training for emergency preparedness, Staff 8 who worked as a housekeeper with the date of hire 07/12/16 had not received initial in-service training for emergency preparedness on the facility emergency preparedness plan. The training records do not exist for staff 3, staff 5, and staff 8.

On 05/08/18 at 12:11 pm the surveyor asked the human resource supervisor, and Chief Executive Officer for documentation of training in-service for existing staff members, volunteers and individuals providing services under arrangement/contract. The human resource supervisor stated she could not find documentation of initial in-service training for three staff from the previous human resource supervisor. The emergency preparedness training documentation does not exist.

Based on observation and interview the facility failed to ensure a required means of egress was not equipped with a deadbolt lock that requires two actions to open from the egress side.

Findings:

On 05/07/18 at 10:36 am deadbolt locks were observed on patient room #101 on the north hallway, a soiled utility closet, sterile processing door room #175, patient room re-purposed into doctor's sleeping room and patient room #208. Two barrel latches were observed on doors in the kitchen of the facility.

On 05/07/18 at 10:37 am the facility manager was asked why the deadbolt's were installed on the exit access corridor patient room doors and he stated in order to secure each of the rooms. He stated he would remove the deadbolt's from the doors in order to comply with fire code requirement for them to be opened with one action. He stated he would also remove the barrel latches.

Based on observation and interview the facility failed to ensure auxiliary spaces where combustible materials are do not have louvers.

Findings:

On 05/07/18 at 10:02 am a louver was observed in the corridor wall near the gift shop at the front entrance.

On 05/07/18 at 10:04 am the surveyor asked the facility manager why a transfer grill/louver was installed into the corridor wall. The facility manager stated he would take care of the opening in the corridor wall.




Corridor - Openings
Transfer grilles are not used in corridor walls or doors. Auxiliary spaces that do not contain flammable or combustible materials are permitted to have louvers or be undercut.
18.3.6.5.1, 19.3.6.5.2, 8.3

Based on observation and interview the facility failed to ensure facility electrical
wiring and equipment was in accordance with the National Electrical Code.

Findings:

On 05/03/18 at 10:32 am a microwave was observed plugged into a power tap in office labeled as room #257.

On 05/03/18 at 10:35 am the surveyor asked the facility manager why the microwave was plugged into a power tap. He stated he did not know why and he has trained staff to not use them. He stated he would remove the power tap and retrain staff in the area.

On 05/07/18 at 10:18 am a medivator was observed in the surgical suite without a current inspection label.

On 05/07/18 at 10: 19 am the facility manager was asked if they had the medivator inspected before placing it in service and do they have a maintenance program for the changing of the the several filters as recommended by the manufacturer. He stated the medivator was not inspected before being placed in service and they would get a contract with their current bio med vendor.

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

Findings:

On 05/01/18 at 1:00 pm the fire door and fire rated frame assembly located at the entrance to the surgical suite was observed to have four holes in the frame where a door closer was once installed.

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

On 05/01/18 at 1:03 pm the surveyor asked the facility manager for the annual fire rated door assembly inspections. The plant manager stated the inspection was not completed for 2017 and the documentation does not exist.

Based on record review and interview the facility failed to ensure the facility's smoke evacuation system was tested and maintained.

Findings:

Record review of the facility fire alarm system annual inspection showed it did not include inspection and maintenance of the surgical suite smoke evacuation system for operating room #1. The documentation for the smoke evacuation system does not exist.

On 05/03/18 at 2:07 pm the surveyor asked the facility manager for the smoke evacuation system inspection/maintenance for the operating rooms for 2016, 2017 and 2018. He stated the smoke evacuation system has not been inspected.

Based on observation and interview the facility failed to ensure medical gas cylinders were properly stored and protected from weather.

Findings:

On 05/03/18 at 2:14 pm the surveyor observed a group of small metal medical gas cylinders standing on the ground with a metal chain link chain lying at the lower end of the cylinders. The chain link chain was not tight enough or high enough around the medical gas cylinders to keep them secured in the event someone ran into them. The surveyor saw a metal trash can with debris inside sitting directly next to the reserve medical gas oxygen cylinders and also observed two "H" sized medical gas cylinders stored without safety caps in place. The surveyor also observed two "E" sized oxygen cylinders lying unsecured in a wheelbarrow with standing water in the wheelbarrow.

On 05/03/18 at 2:15 pm the surveyor asked the facility manager why the medical gas cylinders where not properly secured. He stated he did not know why and will properly secure them. The surveyor asked the facility manager why trash cans were stored next to the reserve oxygen cylinders. He stated he will move the trash cans our of the area. The surveyor asked the facility manager why the two "E" oxygen cylinders were lying in the wheelbarrow with standing water. He stated they were just placed there and it had just rained recently but he stated he would remove the tanks.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed and failed to ensure the generator's transfer switch was on a periodic preventative maintenance program.

Findings:

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

On 05/01/18 at 1:52 pm the plant operations manager was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016 and 2017. The plant operations manager stated the annual emergency generator fuel quality tests have never been done and the documents do not exist.

Record review showed the generator documentation did not include transfer switch maintenance for 2015, 2016 and 2017.

On 05/04/18 at 10:25 am the surveyor asked the facility manager if the emergency generator automatic transfer switch has a preventative maintenance program. The facility manager stated no but will add the transfer switch to the annual emergency generator maintenance program.

Based on observation and interview the facility failed to ensure no extension cords were used as a substitute for fixed wiring.

Findings:

On 05/07/18 at 9:47 am a green three outlet extension cord was observed to be in use in the doctor's sleeping room with a refrigerator and microwave plugged into it.

On 05/07/18 at 9:53 am the surveyor asked the chief nursing officer why is there a green extension cord in the doctor's sleeping room. The chief nursing officer stated she wanted to go into the doctor's sleeping room and see the extension cord. The chief nursing officer stated yes she saw the extension cord in the doctor's sleeping room and they would remove it immediately.