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Based on record review and interview the facility failed to ensure addressing their patient population within the facility emergency preparedness plan as required at CFR 482.15(a).

Findings:

Record review showed the facility emergency preparedness plan did not address or include the facility's patient/client population. The facility emergency preparedness plan did not contain strategies the facility would or will put in place to address the needs of at-risk or vulnerable patient populations it serves, or the services the facility would be able to provide during an emergency event.

On 03/03/20 at 11:43 am the surveyor asked staff A to see where in the facility emergency preparedness plan the facility addressed the patient/client population they serve. Staff A stated they will add the patient population information.

Based on record review and interview the facility failed to ensure annual test and balance inspections were competed and the facility relative humidity (RH) guidelines were in accordance with ASHRAE 170-2008 ventilatory standards as required.

Findings:

Record review showed the facility did not complete annual test and balance inspections to ensure ASHRAE 170-2008 ventilatory standards were being followed as required.

Record review showed the facility's temperature and RH logs RH range to be 20-60% RH instead of the required 30-60% RH.

On 03/03/20 at 1:56 pm staff A was asked for the annual test and balance inspection reports for the last three years 2019, 2018 and 2017. The surveyor asked Staff A why they did not complete the last three years of test and balance inspections. Staff A stated he believed it was due to the bankruptcy issues.

On 03/04/20 at 9:42 am the surveyor asked Staff A why the RH range on the temperature and RH logs showed 20-60% RH instead of 30-60% RH as required. Staff A stated they follow the association of operating room nurses AORN guidelines but will forward the information to the appropriate medical staff.

Based on record review and interview the facility failed to maintain their sprinkler system in accordance with NFPA 25 as required.

Findings:

Record review showed the facility did not complete annual sprinkler inspections for 2017 and 2018 as required.

On 03/03/20 at 3:07 pm the surveyor asked staff A why the two years of annual inspection for the sprinkler was not completed. Staff A stated they were going through the bankruptcy and it must not have been scheduled.

Based on record review and interview, the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required in NFPA 101, 2012 Edition, Chapter 19.7.1.4 through 19.7.1.7.

Findings:

Record review of the facility's fire drill documentation showed each fire drill did not include verification of a transmission of a fire alarm signal.

On 03/03/20 at 10:25 am staff A was asked to show the surveyor where they document how they verify the transmission of a fire alarm signal. Staff A stated they did not document it on the fire drill report forms but will add it from this point on.

Based on observation and interview the facility failed to ensure trash collection receptacles did not exceed 32 gallons in capacity within any 64 sqft area as required.

Findings:

On 03/04/20 at 11:34 am the surveyor observed a 30 gallon Rubbermaid trash receptacle with two 13 quart metal trash receptacles in operating room #1, in operating room #2 the surveyor observed a 30 gallon Rubbermaid trrash receptacle with three 13 quart metal trash receptacles and in the GI procedure room one 30 gallon Rubbermaid trash container with a 13 quart metal trash receptacle and a 13 gallon plastic yellow trash receptacle which exceeds the 32 gallons within a 64 sqft area requirement in code for those three areas.

On 03/04/20 at 11:42 am the surveyor asked staff A why there were so many trash receptacles within the operating rooms and GI procedure room. Staff A asked the surveyor if it would be ok if the trash containers had lids on them. The surveyor stated code does not make provision for acceptance if any trash receptacle has a lid or not. Staff A stated they would remove the containers so there would not be over 32 gallons within a 64 sqft area.

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 and 2018 were not completed.

On 03/03/20 at 12:33 pm the surveyor asked Staff A for the annual fire rated door assembly inspections. Staff A stated the inspection was not completed for 2017, 2018 and the documentation does not exist.

Based on record review and interview the facility failed to ensure the building system risk assessments for the facility (EES) essential electrical system and medical gas system was completed as required.

Findings:

Record review showed the building systems risk assessments for the facility essential electrical risk assessments and medical gas system was not completed for 2019, 2018, or 2017. The building systems risk assessment does not exist.

On 03/03/20 at 12:12 pm the surveyor asked the staff A for the building systems risk assessments for EES and the facility medical gas system. Staff A stated they were not familar with the requirement but will get it completed.

Based on record review and interview the facility failed to ensure annual impedance testing/maintenance to electrical receptacles in patient care areas and the line isolation monitors (LIM) as required.

Findings:

Record review showed the facility did not complete impedance testing for operating room one and two's LIM and all facility patient care related electrical receptacles as required.

On 03/03/20 at 11:47 am the surveyor asked staff A why the impedance testing has not been completed. Staff A stated they do not have a vendor on contract because of going through bankruptcy but will get the impedance testing scheduled.

Based on record review and interview the facility failed to ensure monthly and yearly emergency generator load bank tests were completed as required.

Findings:

Record review showed the monthly generator load banks were not conducted for 2017, or 2018 and the yearly load bank for 2017 was not completed as required.

On 03/03/20 at 1:23 pm the surveyor asked staff A why the emergency generator has not been exercised monthly and yearly as required. Staff A stated when he was in Kansas they did not have to do monthly's and that something must have changed in code.

Based on observation and interview the facility failed to ensure all electrical equipment was inspected and maintained as either UL 1363A or UL 60601-1 for power strips providing power to patient care-related electrical equipment as required under CMS.

Findings:

On 03/03/20 at 11:51 am the surveyor observed a power strip in operating room one which also had an inspection sticker which showed the next inspection due was Feb/2015. The surveyor observed a power strip in operating room two which did not have a current inspection sticker.

On 03/03/20 at 11:53 am the surveyor asked staff A why the power strips in the operating room had not been inspected or taken out of service until being inspected. Staff A stated they will get the power strips inspected before they are used again.