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Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness Plan to include the sharing of information on the facility's patients at risk, and the services provided during an emergency with the local emergency planning group, in one of one plans.

Findings include:

Document review on October 18, 2018, at 11:00 a.m., revealed the facility failed to share information about the facility's patients that may require special care during an emergency or evacuation and the facility's services that can be provided during an emergency event, with local emergency planners.

Interview with the Vice President of Support Services (VPSS) on October 18, 2018, at 11:00 a.m., confirmed the facility failed to share information about the facility's patients that may require special care during an emergency or evacuation and the facility's services that can be provided during an emergency event, with local emergency planners.

Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness Plan to include sheltering in place, in one of one Emergency Preparedness Plans.

Findings include:

Document review on October 18, 2018, at 11:30 a.m., revealed the facility lacked an Emergency Preparedness Plan, to include when to shelter in place, how long the facility can shelter in place before the facility must be evacuated, and when the evacuation process must begin.

Interview with the VPSS on October 18, 2018, at 11:30 a.m., confirmed the facility lacked an Emergency Preparedness Plan to include when to shelter in place, how long the facility can shelter in place before the facility must be evacuated, and when the evacuation process must begin.

Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness Plan to include contact information for Federal emergency disaster staff, in one of one Emergency Preparedness Plans.

Findings include:

Document review on October 18, 2018, at 12:00 p.m., revealed the facility lacked an Emergency Preparedness Plan to include the contact information for Federal Emergency Disaster Staff.

Interview with the VPSS on October 18, 2018, at 12:00 p.m., confirmed the facility lacked an Emergency Preparedness Plan to include the contact information for Federal Emergency Disaster Staff.

Based on observation and interview, the facilty failed to maintain fire barriers with non-health care occupancies in one of one fire barrier with a non-health care occupancy.

Findings include:

1. Observation on October 11, 2018, at 11:00 a.m., revealed the fire door tag, on one of the doors to the Medical Arts Building, was painted and illegible.

Interview with the Facility Director on October 11, 2018, at 11:00 a.m., confirmed the above fire door tag was illegible.

Based on observation and interview, the facilty failed to maintain two-hour fire barrier horizontal exits in two of four barriers.

Findings include:

1. Observation on October 10, 2018, at 11:45 a.m., revealed the fire barrier between 01/02 components (main lobby) had fire door tags that were painted and illegible.

Interview with the Maintenance Supervisor on October 10, 2018 at 11:45 a.m., confirmed the fire door tag was illegible.

2. Observation on October 10, 2018, at 1:35 p.m., revealed the fire barrier near patient room 33 had unsealed data wires penetrating the wall.

Interview with the Maintenance Supervisor on October 10, 2018, at 1:35 p.m., confirmed the unsealed fire barrier penetration.

Based on observation and interview, the facilty failed to maintain vertical openings at one of one stair tower.

Findings include:

1. Observation on October 10, 2018, at 10:30 a.m., revealed the North wing exit stair tower, had a large ultrasonic machine stored on the inside landing of the stair tower.

Interview with the Maintenance Supervisor on October 10, 2018, at 10:30 a.m., revealed the storage in the above exit stair tower.

Based on observation and interview, the facilty failed to maintain hazardous areas on one of two building levels.

Findings include:

1. Observation on October 10, 2018, at 11:10 a.m., revealed the facility converted second floor suite 2300, exam room 6, into a storage room to house over twenty large items packaged in cardboard boxes. No state plan approval was submitted for the change of use of a room. nor was an occupancy inspection granted.

Interview with the Maintenance Supervisor on October 10, 2018, at 11:10 a.m., confirmed the above change in use of a room, without state approvals.

Based on observation and interview, the facilty failed to maintain fire alarm systems in one of twelve smoke compartments.

Findings include:

1. Observation on October 11, 2018, at 9:30 a.m., revealed the fire alarm pull station notification device was obstructed with an Operating Room table in the corridor, outside of the Operating Room suite.

Interview with the Maintenance Supervisor on October 11, 2018, at 9:30 a.m., confirmed the above fire alarm device was obstructed.

Based on observation and interview, the facilty failed to maintain fire sprinkler systems in two of twelve smoke compartments.

Findings include:

1. Observation on October 10, 2018, at 1:30 p.m., revealed the fire sprinkler pipe above the ceiling tile, in the corridor between rooms 21 and 23 had additional loads:
a. wires attached to the pipe
b. flex duct draped over the sprinkler pipe

Interview with the Maintenance Supervisor on October 10, 2018, at 1:30 p.m., confirmed the above fire sprinkler pipe had additional loads.

2. Observation on October 11, 2018, at 10:20 a.m., revealed the storage room at the back of the Laboratory had a box placed on the shelf within 18 inches of the fire sprinkler head.

Interview with the Maintenance Supervisor on October 11, 2018, at 10:20 a.m., confirmed the above fire sprinkler had storage with 18 inches.

Based on observation and interview, the facilty failed to maintain electrical systems in one of twelve smoke compartments.

Findings include:

1. Observation on October 11, 2018, at 10:10 a.m., revealed Emergency Department Suite corridor, to the left side of the nurses station, had an open junction box above the ceiling tile.

Reference NFPA 70, 314.28 (c).

Interview with the Maintenance Supervisor on October 11, 2018, at 10:10 a.m., confirmed the above open junction box.

Based on observation and interview, the facilty failed to maintain electrical receptacle ground-fault circuit interrupters (GFCI) in one of two Therapy Departments.

Findings include:

1. Observation on October 10, 2018, at 11:30 a.m., revealed the first floor, suite 1400 Occupational Therapy Department, had a hydrocollator that was not plugged into a GFCI electrical receptacle.

Interview with the Maintenance Supervisor on October 10, 2018, at 11:30 a.m., confirmed the above hydrocollator was not plugged into a GFCI receptacle.

Based on observation and interview, the facilty failed to maintain electrical power cords on one of two building levels.

Findings include:

1. Observation on October 10, 2018, between 10:50 a.m., and 11:00 a.m., revealed the following locations were utilizing extension cords:
a. (10:50 a.m.) second floor, suite 2500, lounge near exam room 3, (extension was also plugged into a 3 X 1 electrical adapter)
b. (11:00 a.m.) second floor, suite 2200, consultation/office room

Interview with the Maintenance Supervisor on October 10, 2018, at 11:00 a.m., confirmed the above locations were utilizing extension cords.

Based on observation, document review and interview, the facilty failed to maintain piped-in medical gas for one of one system.

Findings include:

1. Document review on October 10, 2018, at 10:00 a.m., revealed the last medical gas inspection of March 6, 2018, noted the following Central Supply deficiency: "lag set point too low". Facility lacked documentation that this item has been corrected.

Interview with the Maintenance Supervisor on October 10, 2018, at 10:00 a.m., confirmed the above deficiency noted on the last medical gas inspection, with no indication that this item has been corrected.

2. Observation on October 11, 2018, at 9:30 a.m., revealed the Operating Room suite corridor (behind charting station) had a bed obstructing medical gas shut-off valves.

Interview with the Maintenance Supervisor on October 11, 2018, at 9:30 a.m., confirmed the above shuts-off valves were obstructed.