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Based on document review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan included a communication plan listing contact information for Federal, State, tribal, regional, and local emergency preparedness staff, affecting the entire facility.

Findings include:

1. Document review on November 6, 2019, at 9:50 am, revealed there was no contact information included in the Emergency Preparedness plan for the State Licensing and Certification Agency and the Office of the State Long-Term Care Ombudsman.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am, confirmed the facility failed to develop an Emergency Preparedness Plan to include contact information for the above listed emergency officials.

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness communication plan that includes a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting the entire facility.

Findings include

1. Document review on November 6, 2019, at 10:20 am, revealed the facility failed to develop an emergency plan that includes a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, an Incident Command Center, or designee.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am, confirmed the EP plan did not include a communication plan for providing information about their occupancy, in the event of an emergency.

Based on document review and interview it was determined that the facility failed to develop and maintain an emergency preparedness training program for staff and individuals providing services to the facility, affecting the entire facility.

Findings include:

1. Document review on November 6, 2019, at 11:40 am, revealed the facility failed to provide documentation showing their emergency preparedness training program for staff, individuals providing services to the facility including volunteers.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the documentation of their emergency preparedness training was unavailable at time of survey.

Based on an observation and interview, it was determined the facility failed to maintain accurate floor plans outlining designated rated partitions, affecting one of six floors.

Findings Include:

1. Document review on November 6, 2019, at 11:50 am, revealed the provided floor plans indicated the wall of Storage Room 562 as a 2-hour rated wall. The wall above the door was stenciled as a 1-hour wall.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the provided floor plans did not match the stenciling on the wall.

Based on an observation and interview, it was determined the facility failed to ensure vertical openings between floors maintained a fire resistance rating, affecting two of six floors.

Findings include:

1. Observation on November 7, 2019, at 10:10 am, revealed, in 2nd floor Falls 4 electrical room, unsealed penetrations of the ceiling assembly around conduits.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the unsealed vertical penetrations.

Based on an observation and interview, it was determined that the facility failed to maintain hazardous areas, affecting two of six floors.

Findings include:

1. Observation on November 6, 2019, at 11:30 am, revealed, in 1st floor elevator lobby, the rated access door to the oxygen supply valves lacked a self-closure.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the rated door lacked a self-closure.


2. Observation on November 6, 2019, at 12:45 pm, revealed, in 5th floor soiled utility room had an unsealed penetration of the rear wall on both sides.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the unsealed penetration.

Based on an observation and interview, it was determined the facility failed to ensure fire alarm control functions were maintained, affecting three of four elevators.

Findings include:

1. Observation on November 6, 2019, at 11:45 am, revealed, during the fire-alarm test, the following elevators did not recall: E025, E027, and E028.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the elevators failed to recall during the fire-alarm test.

Based on an observation, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of six floors.

Findings include:

1. Observation on November 7, 2019, at 10:20 am, revealed, in 5th floor electrical room, the spare sprinklers and wrench were not stored in a sprinkler cabinet.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the sprinkler spares were not properly stored in a sprinkler cabinet.

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly, affecting two of twelve required drills.

Findings include:

1. Document review on November 6, 2019, at 9:30 am, revealed the facility could not provide documentation that fire drills had been conducted for the following times:

a. 3rd quarter 2019, 3rd shift;
b. 4th quarter 2018, 2nd shift

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the missing fire drills.

Based on an observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting three of six floors.

Findings include:

1. Observation on November 7, 2019, between 9:30 am, and 10:00 am, revealed electrical panels with missing circuit breaker protective blanks in the following locations:

a. 9:30 am, Substation Falls 4, Panel DEP-4;
b. 9:55 am, 2nd floor Falls 4, Panel EGAS-2;
c. 10:00 am, 2nd floor Falls 4, Panel EEAS-2.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed electrical equipment was missing protective covers.


2. Observation on November 7, 2019, between 9:45 am, and 9:50 am, revealed junction boxes with exposed inner wiring due to missing cover plates in the following locations:

a. 9:45 am, Substation Falls 4;
b. 9:55 am, Falls 2 main switchgear room, above panels.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed the missing cover plates.

Based on document review and interview, it was determined the facility failed to ensure that electrical receptacles were tested at patient bed locations within the facility, affecting the entire facility.

Findings include:

1. Document review on November 6, 2019, at 10:50 am, revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity;
b. correct polarity of the hot and neutral connections;
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

Interview at the exit conference with the Chief Operating Officer on November 7, 2019, at 11:30 am confirmed testing of electrical receptacles was not completed as required.