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Based on the facility document review and staff interview, the facility failed to establish and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. Facility census 2.

Findings include:

A. During the facility emergency preparedness document review conducted on 12/19/17 between the hours of 12:00 p.m. and 2:00 p.m., the facility failed to complete the following emergency preparedness elements:

1. A documented facility based and community-based risk assessment were not available for review.

2. Policies and procedures addressing the subsistence needs of staff and patients were not available for review.

3. Policies and procedures for tracking of staff and patients were not available for review.

4. Policies and procedures for safe evacuation from the hospital including consideration of care and treatment needs of evacuees: staff responsibilities; transportation; identification of evacuation location(s) were not available for review.

5. Policies and procedures for Sheltering were not available for review.

6. Policies and procedures for Medical Doctors were not available for review.

7. Policies and procedures for volunteers were not available for review.

8. Policies and procedures for roles under a Waiver declared by Secretary not available for review.

9. Policies and procedures for a Communication Plan were not available for review.

10. Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.

11. Primary and alternate means for communication plans were not available for review.

12. Policies and procedures for sharing information on occupancy needs were not available for review.

13. Policies and procedures for emergency prep and a training program were not available for review.

14. An emergency training program was not available for review.

B. The aforementioned deficiencies were discussed with the Administrator, the Chief Nursing Officer and the Maintenance Technician on 12/10/17 at approximately 2:00 p.m. and agreed these deficiencies needed corrected.

Based on document review and staff interview, the facility failed to provide emergency lighting in accordance with NFPA (National Fire Protection Association 101. Facility census 2.

Findings include:

1. During the document review on 12/18/17, between the hours of 11:00 a.m. and 4:00 p.m., revealed the facility failed to conduct annual tests of the emergency lighting in accordance with NFPA (National Fire Protection Association) 101.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with NFPA (National Fire Protection Association) 101. Facility census 2.

Findings include:

1. During the facility inspection tour conducted on 12/19/17 between the hours of 8:00 a.m. and 11:00 a.m., revealed the facility failed to provide door closures on storage rooms in accordance with NFPA (National Fire Protection Association) 101 for the following areas: storage rooms #1 and #2, #19, and the Hollyhost Twig storage area located in Purchasing, room 202 located on the first floor, the vending area storage room, and the furnace room located in the Bantug Clinic.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 2/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on the facility document review and staff interview, the facility failed to protect the range hood inspection in accordance with NFPA (National Fire Protection Association) 101 and 96 . Facility census 2.

Findings include:

1. During the facility document review conducted on 12/18/17 between the hours of 11:00 a.m. and 4:00 p.m., revealed the facility failed to provide documentation of the first half of the required semi-annual inspection of the range hood in accordance with NFPA (National Fire Protection Association) 101 and 96.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on the facility document review and staff interview, the facility failed to provide evidence of maintaining the Fire Alarm System in accordance with NFPA (National Fire Protection Association) 101 and 72. Facility census 2.

Findings include:

1. During the facility document review, the facility failed to provide evidence of the annual inspection of the Fire Alarm System and the Fire Damper inspections in accordance with NFPA (National Fire Protection Association) 101 and 72.

2. During the facility document review, the facility failed to provide evidence of smoke detector sensitivity testing in accordance with NFPA (National Fire Protection Association) 72.

3. The aforementioned deficiencies were discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed these deficiencies needed corrected.

Based on the facility document review and staff interview, the facility failed to provide a "Fire Alarm - Out of Service" policy and procedure in accordance with NFPA (National Fire Protection Association) 99. Facility census 2.

Findings include:

1. During the facility document review conducted on 12/18/19 between the hours of 11:00 a.m. and 4:00 p.m., revealed the facility failed to provide a policy and procedure for "Fire Alarm - Out of Service" policy and procedure in accordance with NFPA (National Fire Protection Association) 99.

Based on observation and staff interview, the facility failed to provide smoke detection systems in spaces open to the corridors in accordance with NFPA (National Fire Protection Association) 101. Facility Census 2.

Findings include:

1. During the facility inspection tour on 12/19/17 between the hours of 8:00 a.m. and 11:00 a.m., revealed the facility failed to provide a smoke detection system in room 226 (Purchasing) in accordance with NFPA (National Fire Protection Association) 101.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on observation during the facility inspection tour and staff interview, the facility failed to provide a sprinkler system installed in accordance with NFPA (National Fire Protection Association) 13. Facility census 2.

Findings include:

1. During the facility inspection tour on 12/19/17 between the hours of 8:00 a.m. and 11:00 p.m. revealed sprinkler heads in room 206, 207 and Medical Records were found restricted and not in accordance with installation specifications of NFPA (National Fire Protection) 13.

2. The aforementioned deficiencies were discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed these deficiencies needed corrected.

Based on observation during the facility inspection tour and staff interview, revealed the facility failed to maintain the sprinkler system in accordance with NFPA (National Fire Protection Association) 25. Facility census 2.

Findings include:
1. During the facility inspection tour conducted on 12/19/17 between the hours of 8:00 a.m. and 11:00 a.m., revealed wires laying on sprinkler piping above the ceiling next to 204, flex duct on the sprinkler piping above ceiling next to 204, wires on sprinkler pipes above the ceiling next to the nurse station, wires on sprinkler pipes above ceiling next to 232 and wires on sprinkler pipes above ceiling in purchasing next to storage room #1.

2. The aforementioned findings were discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed these deficiencies needed corrected

Based on observation during the facility inspection tour and staff interview, revealed the facility failed to provide corridor doors capable of resisting the passage of smoke in accordance with NFPA (National Fire Protection Association) 101. Facility census 2.

Findings include:

1. During the facility inspection tour on 12/19/17 between the hours of 8:00 a.m. and 11:00 a.m. revealed a hole the corridor door leading to Purchasing and a hole the corridor door leading to the Bantug Clinic not in compliance with the requirements of NFPA (National Fire Protection Association) 101.

2. The aforementioned deficiencies were discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed these deficiencies needed corrected.

Based on observation during the facility inspection tour and staff interview, revealed the facility failed to provide electrical wiring in accordance with NFPA (National Fire Protection Association) 70. Facility census 2.

Findings include:

1. During the facility inspection tour conducted on 12/19/17 between the hours of 8:00 a.m. and 11:00 a.m. revealed temporary wiring above the ceiling next to room 202 and romex wiring above the ceiling next to Pulmonary installed not in accordance with NFPA (National Fire Protection Association) 70.

2. The aforementioned deficiencies were discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed these deficiencies needed corrected.

Based on the facility document review and staff interview, the facility failed to conduct fire drills in accordance with NFPA (National Fire Protection Association) 101. Facility census 2.

Findings include:

1. During the facility document review conducted on 12/18/17 between the hours of 11:00 a.m. and 4:00 p.m., revealed the 1st quarter evening shift and the 2nd quarter evening shift and the 3rd quarter fire drills held with one minute of each other and not in compliance with the requirements of NFPA (National Fire Protection Association) 101.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on the facility document review and staff interview, revealed the facility failed to maintain the electrical system maintenance and testing requirements in accordance with NFPA (National Fire Protection Association) 99. Facility census 2.

Findings include:
1. During the facility document review conducted on 12/18/17 between the hours of 11:00 a.m. and 4:00 p.m. revealed the facility failed to test receptacles located at patient bed locations in accordance with NFPA (National Fire Protection Association) 99.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on the facility document review and staff interview, revealed the facility failed to maintain the generators in accordance with NFPA (National Fire Protection Association) 110. Facility census 2.

Findings include:

1. During the facility document review conducted on 12/18/17 between the hours of 11:00 a.m. and 4:00 p.m., revealed the generators batteries were not tested in accordance with NFPA (National Fire Protection Association) 110.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12?19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on the facility document review and staff interview, the facility failed to maintain testing and maintenance requirements for Patient Care Related equipment in accordance with NFPA (National Fire Protection Association) 99. Facility census 2.

Findings include:

1. During the facility document review conducted on 12/18/17 between the hours of 11:00 a.m. and 4:00 p.m. revealed the facility failed to conduct testing and maintenance of patient beds in accordance with NFPA (National Fire Protection Association) 99.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.

Based on the facility document review and staff interview, the facility failed to provide personnel concerned with the application, maintenance and handling of oxygen cylinders training on the risks in accordance with NFPA (National Fire Protection Association) 99. Facility census 2.

Findings include:

1. During the facility document review conducted on 12/18/17 between the hours of 11:00 a.m. and 4:00 p.m. revealed the facility failed to provide training on the risks of handling oxygen cylinders in accordance with NFPA (National Fire Protection Association) 99.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Technician on 12/19/17 at approximately 2:00 p.m. and agreed this deficiency needed corrected.