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Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Fire & Life Safety Coordinator that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:
1. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
2. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the disaster plan provided by the facility to the surveyor did not have an annual review date.
3. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m.,the facility did not have current transportation agreements.
4. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the facility did not have current transfer agreements with equivalent facilities
Surveyor was accompanied by the Maintenance Director and Fire & Life Safety Coordinator who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Fire Life Safety Coordinator that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the facility had no documentation on conducting 1st, 2nd & 4th quarter Dayshift shift fire drills.
Surveyor was accompanied by the Maintenance Director and Fire Life Safety Coordinator who acknowledged the existence of these conditions.

Based on observation and interviews it was determined through on-going dialog with the Maintenance Director and Fire & Life Safety Coordinator that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks in universe. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
On 06/29/2016, at 12:07 p.m., there was a room, adjacent to 2nd floor mechanical room labelled "Oxygen Storage" that had a rack of oxygen cylinders in a storage closet with electrical connections and outlets below 152cm.
Surveyor was accompanied by the Maintenance Director and Fire & Life Safety Coordinatorwho acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Fire & Life Safety Coordinator that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:
1. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
2. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the disaster plan provided by the facility to the surveyor did not have an annual review date.
3. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m.,the facility did not have current transportation agreements.
4. On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the facility did not have current transfer agreements with equivalent facilities
Surveyor was accompanied by the Maintenance Director and Fire & Life Safety Coordinator who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Fire Life Safety Coordinator that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
On 06/30/2016, during record review between 9:00 a.m. and 11:00 a.m., the facility had no documentation on conducting 1st, 2nd & 4th quarter Dayshift shift fire drills.
Surveyor was accompanied by the Maintenance Director and Fire Life Safety Coordinator who acknowledged the existence of these conditions.

Based on observation and interviews it was determined through on-going dialog with the Maintenance Director and Fire & Life Safety Coordinator that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks in universe. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
On 06/29/2016, at 12:07 p.m., there was a room, adjacent to 2nd floor mechanical room labelled "Oxygen Storage" that had a rack of oxygen cylinders in a storage closet with electrical connections and outlets below 152cm.
Surveyor was accompanied by the Maintenance Director and Fire & Life Safety Coordinatorwho acknowledged the existence of these conditions.