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Based on document review, the facility failed to develop and maintain a comprehensive emergency preparedness program utilizing an all hazards approach.

Findings include:

On 4/25/18, review of the facilities "Disaster/Evacuation Plan" revealed the program did not include the use of an all-hazards approach. The plan provided at the time of the survey was dated "September 2000".

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on document review, the facility failed to develop and maintain a comprehensive emergency preparedness program that is updated at least annually.

Findings include:

On 4/25/18, the facilities "Disaster/Evacuation Plan" did not provide any evidence that it had been reviewed or updated after September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on document review, the facility failed to develop and maintain a comprehensive emergency preparedness program that was based on a documented, facility-based and community-based risk assessment.

Findings include:

On 4/25/18, a review of the "Disaster/Evacuation Plan" revealed that it was not based on a facility-based and community-based risk assessment, utilizing an all-hazards approach.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on document review, the facility failed to develop and maintain a comprehensive emergency preparedness program that addressed the patient/client population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

Findings include:

On 4/25/18, a review of the "Disaster/Evacuation Plan" revealed the facilities plan did not include an assessment of the patient/client population, types of services the agency would provide in an emergency and delegation of authority and a succession plan.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility failed to provide documented evidence that efforts were made to contact officials to engage in collaborative and cooperative planning for an integrated emergency response.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on document review, the facility failed to develop preparedness policies and procedures, based on the emergency plan, risk assessment and the communication plan.

Findings include:

On 4/25/18, a review of the "Disaster/Evacuation Plan" revealed the facilities plan did not include preparedness policies and procedures, based on the emergency plan, risk assessment and the communication plan.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on document review, the facility failed to develop a plan that included the subsistence needs for staff and residents, whether they evacuated or sheltered in place.

Findings include:

On 4/25/18, a review of the "Disaster/Evacuation Plan" revealed the facility failed to develop a plan that included for the subsistence needs for staff and residents, whether they evacuated or sheltered in place.

The Dietary Manager (DM) explained that the plan was based on a need for three day's of supplies. The DM explained the food and water amounts were based on residents and did not include staff and guests that might need to shelter in place at the facility.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on document review, the facility failed to develop a plan to track the location of on-duty staff and sheltered patients in the facility's care during an emergency. The facility failed to develop a plan for documenting the names and locations of on-duty staff and sheltered patients relocated during an emergency.

Findings include:

On 4/25/18, a review of the "Disaster/Evacuation Plan" revealed the facility failed to develop a plan that included the tracking of patients, residents and staff whether sheltered in place or evacuated to another facility.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide a process for safe evacuation from the facility, which included consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did have a plan for evacuation, but there was no evidence the plan had been reviewed or updated annually. The plan reviewed was dated September 2000. The evacuation plan did not address primary and alternate means of communication with external sources of assistance.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide a plan to shelter in place for patients, staff, and volunteers who remain in the facility.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a plan for sheltering in place. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did have a limited plan for medical record management, but there was no evidence the plan had been reviewed or updated annually. The plan reviewed was dated September 2000. The "Health Information" plan appeared to only address the preparation of current patient charts for transfer to another location. It was not clear how patient charts and or medical records of past patients/residents would be preserved.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide a process for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a plan for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide policies and procedures for the development of arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did have a limited plan for the development of arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. However, there was no evidence the plan had been reviewed or updated annually. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide a policy and/or procedure concerning the role of the facility under a waiver declared by the Secretary of Health and Human Services, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a policy and/or procedure concerning the role of the facility under a waiver declared by the Secretary of Health and Human Services, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a complete emergency preparedness communication plan that complies with Federal, State and local laws. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that included the names and contact information for: staff, entities providing services under arrangement, patients' physicians, other facilities and volunteers.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a communication plan that included the names and contact information for: staff, entities providing services under arrangement, patients' physicians, other facilities and volunteers. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide contact information for: Federal, State, tribal, regional, or local emergency preparedness staff; the State Licensing and Certification Agency; the Office of the State Long-Term Care Ombudsman; and other sources of assistance.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have contact information for: Federal, State, tribal, regional, or local emergency preparedness staff; the State Licensing and Certification Agency; the Office of the State Long-Term Care Ombudsman; and other sources of assistance. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to develop a communication plan that provided for a primary and alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency management agencies.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a communication plan that provided for a primary and alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency management agencies. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to provide:
1) a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
2) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
3) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). .

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not develop:
1) a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
2) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
3) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to develop a communication plan that outlined a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have a communication plan that outlined a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, its risk assessment and the communication plan.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, its risk assessment and the communication plan. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to complete the following:
1) Provide emergency preparedness training at least annually.
2) Maintain documentation of the training.
3) Demonstrate staff knowledge of emergency procedures.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not complete the following:
1) Provide emergency preparedness training at least annually.
2) Maintain documentation of the training.
3) Demonstrate staff knowledge of emergency procedures.

The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

Based on documentation review and interview, the facility failed to develop written policies and procedures for emergency and standby power systems.

Findings Include:

On 4/25/18, review of the Emergency Plan revealed the facility did not have written policies or procedures to address emergency and standby power systems. The plan reviewed was dated September 2000.

The Director of Nursing (DON) believed the plan provided was the most current. The DON was in charge of the facility during the survey as the Administrator was away from the office for the week.

National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.9 Stock of Spare Sprinklers.
6.2.9.1* A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.
6.2.9.2 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.
6.2.9.3 The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C).
6.2.9.4 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.
6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For protected facilities having under 300 sprinklers - no fewer than six sprinklers
(2) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(3) For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers
6.2.9.6* One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system.
6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.
6.2.9.7.1* The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special requirements of Section 8.6 through Section 8.12 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.
5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.


Based on observation, the facility failed to maintain its automatic fire sprinkler system as required.

Findings include:

On 04/25/18, during a tour of the facility the following automatic fire sprinkler system concerns were observed:

1) Observation of the main fire sprinkler riser room revealed the fire sprinkler spare box did not have a list of sprinklers installed on the property along with a listing of the quantity of each type of sprinkler to be contained in the spare cabinet.

2) Observation of the radiology room revealed two sprinklers located within one inch of the ceiling and within two to three inches of metal braces for the radiology equipment. Given the position of the sprinklers in relation to the ceiling and metal braces, the sprinklers would be unable to develop their required spray pattern.

3) Observation of the following fire sprinklers revealed they were loaded with foreign material:
a) Kitchen - sprinkler near hood
b) Patient/Resident Room 114 - two sprinklers
c) Patient/Resident Room 109 - one sprinkler
d) Patient/Resident Room 112 - one sprinkler
e) Patient/Resident Room 101 (bathroom) - one sprinkler
f) Shower Room by Patient/Resident Room 103 - one sprinkler

The Maintenance Technician acknowledged each deficiency at the time of discovery.

INFORMATIONAL NOTE: Observation of the automatic sprinkler riser revealed two gauges dated 2013. Observation of a sticker on the riser pipe revealed the last obstruction test was conducted "8/2013". The gauges are due for replacement in 2018 and the 5 year obstruction test is due to be conducted before August 2018.

National Fire Protection Association (NFPA) 10, Standard for Portable
Fire Extinguishers, 2010 Edition
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31?2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).


Based on observation, the facility failed to install a fire extinguisher at the appropriate height.

Findings include:

On 4/25/18, observation of the fire extinguisher located near the ambulance entrance to the emergency department revealed the extinguisher was installed at 64" above the finished floor. The installed height was 4" above the maximum height.

The Maintenance Technician acknowledged the discrepancy at the time of discovery.

Based on observation, the facility failed to ensure smoke barrier construction was properly sealed at points of penetration.

Findings include:

On 4/25/18, observation of the following areas revealed penetrations in the smoke barrier construction:

1) General Stores Room - four conduit lines, two water lines and blue wires penetrate the wall and are not sealed.

2) Riser Room - conduit lines not sealed.

The Maintenance Technician acknowledged the deficiencies at the time of discovery.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Article 408.4 - Field Identification Required
A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.


Based on observation, the facility failed to 1) ensure that the electrical connections in junction boxes were covered and 2) ensure that the electrical installations within the facility were maintained as required by NFPA 70.

Findings include:

1) On 4/25/18, observation of the mechanical room revealed two uncovered electrical junction boxes.

2) On 4/25/18, observation of the following electrical panels revealed circuit directories that did not include an approved degree of detail that allowed each circuit to be distinguished from all others:

a) EDP
b) EP
c) MDP
d) P
e) A Section I
f) A Section II
g) E
h) EH

The Maintenance Technician acknowledged the deficiencies at the time of discovery and during the exit interview.

Based on document review and interview, the facility failed to provide evidence that smoke and fire door assemblies were inspected and tested not less than annually.

Findings include:

On 4/25/18, document review revealed there was not a program or report that demonstrated all smoke and fire door assemblies had been inspected as required.

The Maintenance Technician acknowledged the deficiency at the time of the exit interview.

Based on document review and interview, the facility failed to provide evidence that identified deficiencies were repaired during an annual gas and vacuum system inspection.

Findings include:

On 4/25/18, document review revealed the facilities gas and vacuum piped systems had been inspected by a qualified vendor on 7/20/17. The vendor noted several deficiencies that included failed flow tests, no zone valves for the vacuum system, and oxygen sensor for an area was on the wrong side of zone valves. The vendor's report did not indicate that corrections had been made.

The Maintenance Technician (MT) explained that the testing had been accomplished, but was unaware if corrections had been made. The MT acknowledged the deficiency at the time of discovery.

National Fire Protection Association (NFPA) 99, Health Care Facilities Code (2012 Edition)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). A low tension value means the ground pin of the attachment plug of the appliance is not making good contact with the grounding blade in the receptacle, thereby defeating the purpose of providing a low-impedance path to ground for the green ground wire of the appliance.


Based on observation and interview, the facility failed to ensure that electrical receptacles were tested annually and the results of those tests were documented.

Findings include:

On 4/25/18, record review revealed there was no evidence that electrical receptacles were tested. Observation of resident rooms revealed the receptacles were not listed as hospital-grade.

The Maintenance Technician acknowledged the deficiency at the time of discovery and during the exit interview.

Based on document review and interview, the facility failed to ensure the Essential Electrical System (EES) was inspected weekly and exercised under load every month in 20-40 day intervals.

Findings include:

On 4/25/18, document review revealed there were two instances the monthly load testing of the EES exceeded the 40 day interval.

1) Load tests were accomplished 1/3/18 and 2/27/18, a 49 day interval.
2) Load tests were accomplished 9/5/18 and 10/23/18, a 47 day interval.

The Maintenance Technician acknowledged the deficiency at the time of discovery.

Based on document review, observation, and interview, the facility failed to produce a record of electrical equipment tests, repairs, and modifications as required.

Findings include:

On 4/25/18, document review revealed there was no current record of electrical equipment tests, repairs, and modifications for the facilities patient-care related electrical equipment (PCREE). Observation of equipment revealed stickers from an outside vendor that confirmed testing had been completed on PCREE in April of 2018.

The Maintenance Technician (MT) explained the PCREE had been tested in April, but a report had not been received. The MT acknowledged the deficiency at the time of discovery.