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Based on record review and interview, 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:

Review of the EP plan, policies, and procedures on 6/18/19, showed the facility lacked a complete system for determining subsistence needs for staff and patients, particularly specific needs for water, medical and pharmaceuticals for the number of patients and staff who would be sheltering in place.

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

Findings include:

1. Review of the EP plan reflected the plan did not contain specific procedures regarding evacuation of residents, tracking them, and their corresponding needs regarding care, nor was there specific staff responsibilities listed in the EP book.

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 6/18/19, 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 observations, 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 of 3 smoke compartments on the first floor.

Findings include:

1. During an observation on 6/18/19 at 8:03 a.m., the ER corridor was inspected. There was a bench in the corridor for use as a waiting area. It was in the 6 feet to 8 feet distance in the width of the corridor. It was not bolted the floor or the wall.

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 of 1 basement smoke compartment.

Findings include:

1. During an observation on 6/18/19 at 7:30 a.m., the basement exit enclosure near the main entrance was inspected. The stairwell enclosure contained a bicyle and a large seat from a vehicle. Enclosures cannot be used as storage areas.

Based on record review, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1. This affects all locations where the battery powered emergency light fixtures were utilized.

Findings include:

1. Review of the facility records for testing of the emergency lighting showed a lack of supporting documentation for 30 second monthly tests performed on these fixtures, within the last year.

Based on observation, the facility failed to provide illuminated directional exit signs in an exit corridor in accordance with NFPA 101-2012, Sections 7.10 and 7.10.1.2.2. This deficiency affects 1 of 3 smoke compartments on the main level.

Findings include:

1. During an observation on 6/18/19 at 8:24 a.m., the north hallway was inspected. There was a two hour horizontal exit going to the long term care side of the building, and an outside, marked exit, in the corridor near the horizontal exit. There was no visible exit sign going back toward the nurse station at the other end of the corridor to guide residents back to the way of the other exits if they were blocked by smoke and fire at the north end of the corridor.

Based on observations, the facility failed to ensure rooms being used as storage had doors which were able to close, and latch under the power of a self-closing device in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. This deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 6/18/19 at 8:26 a.m., the north hall storage room was inspected. The room was greater than 50 square feet and would not positively latch under the power of the self-closer.

Based on observation and interview, the facility failed to test the fire alarm system as required per NFPA 72-2010, Section 14.6.2.4. This deficiency affects the entire building.

Findings include:

On 6/17/19, review of the 4/30/19 annual fire alarm system inspection report reflected the contractor did not provide an itemized list with the following information, device type, address, location, and the test result as required for the Intiating and Supervisory devices. The alarm testing records were blank in this section of the document.

Based on observation and record review, the facility failed to:
a) document monthly standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1;
b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.
c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1;
d) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.2;
e) ensure sprinkler heads were installed clear of ceiling mounted fixtures 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.

These deficiencies affect the entire building.

Findings include:

1. Review of the facility's quarterly sprinkler inspection reports, reflected the lack of supporting documentation to show the facility's automatic sprinkler systems' gauges were inspected and documented monthly for a wet system.

2. During an observation on 6/18/19 at 7:32 a.m., the basement storage area was inspected. There was a large IT cable zip-tied to a sprinkler pipe, using the pipe as a "run" for the cable.

3. During an observation on 6/18/19 at 7:35 a.m., the basement data room was inspected. There were several tiles out in the room, with some ceiling areas having had many bundles of IT wires running up through the ceiling. The area above the ceiling tiles was greater than 12 inches.

4. During an observation on 6/18/19 at 8:38 a.m., the xray storage room was inspected. The sprinkler head in the room was lacking the escutcheon ring.

5. During an observation on 6/18/19 at 9:03 a.m., the sprinkler head in the LAB suite corridor was found to be blocked by a light.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. The deficiency could affect 2 of 3 smoke compartments.

Findings include:

1. During an observation on 6/17/19 at 3:50 p.m., the portable extinguisher near the server room was inspected. The extinguisher was mounted about 67 inches high, seven inches over the maximum 60 inches.

2. During an observation on 6/18/19 at 7:42 a.m., the portable extinguisher next to the central supply room was inspected. The extinguisher was mounted about 65 inches high, five inches over the maximum 60 inches.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 8.3.3.1, 19.7.6, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). This deficiency affects all of the fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 6/18/19 reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers in the building and show inspections of all components of the fire doors in those barriers.

Based on record review, the facility failed to ensure piped oxygen shutoff valves were properly labeled in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.3.11.2. This deficiency affects 2 fo 3 smoke compartments.

Findings include:

1. During an observation on 6/18/19 at 8:30 a.m., it was determined that none of the piped oxygen shutoff valves were labled with the room numbers currently identifying the rooms. The shutoffs matched the original architect room numbers but were never changed with the current numbers. Some of the identifying room numbers were very difficult to read as well.

Based on observation, the facility 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 deficiency affects the entire building.

Findings include:

1. During an observation on 6/18/19 at 9:07 a.m., the generator was inspected. It was located inside a room outside the building. There was no remote manual stop located outside the room housing the generator.

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 affected 3 of 3 smoke compartments.

Findings include:

1. During an observation on 6/18/19 at 7:55 a.m., the generator room was inspected. The facility was using the room as storage for various items.