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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 02/20/20 at 2:30 pm the surveyor asked staff B to see where in the facility emergency preparedness plan the facility addressed the patient/client population they serve. Staff B stated they could not find where paitent population was addressed but will add it.

Based on record review and interview the facility failed to ensure the initial in-service training for emergency preparedness contained the facility emergency preparedness plan as required.

Findings:

Record review of the facility emergency preparedness training documentation did not show the in-service training included the facility emergency preparedness plan as required.

On 02/20/20 at 12:11 pm the surveyor asked staff C why the facility emergency preparedness pan was not included in the emergency preparedness initial employee training. Staff C stated that several portions of the plan are included but will amend the initial training to included all of the facility emergency preparedness plan.

Based on observation and interview the facility failed to ensure doors in a required means of egress were not equipped with a latch that requires two actions to open or lock that requires the use of a tool or key from the egress side as required.

Findings:

On 02/21/20 at 2:41 pm deadbolt lock with a thumb turn latch was observed on four doors within the radiology department.

On 02/21/20 at 2:41 pm staff C was asked why there were four doors within the radiology department and throughout the hospital. Staff C stated they were working towards removing them but have not been able to remove them all at this point. Staff C stated they would remove all of the thumb turn latch deadbolts to be in compliance.

Based on observation and interview the facility failed to ensure all smoke compartment sprinkler heads were the same temperature as required.

Findings:

On 02/21/20 at 11:17 am the surveyor observed a standard sprinkler head over the administration administrative assistant's desk, and a quick response located on the ceiling in the hallway at the entrance to the administrative assistant's desk. These two sprinkler heads were observed to be located within the same smoke compartment which is non-compliant.

On 02/21/20 at 11:17 am the surveyor asked staff D to look at the two different sprinkler heads located in the administrative area smoke compartment. Staff D stated they will get them corrected.

On 02/21/20 at 11:32 am the surveyor observed a standard sprinkler head in the egress corridor of a patient room hallway and a quick response sprinkler head located in a house keeping closet within the same smoke compartment.

On 02/21/20 at 11:32 am the surveyor asked staff D to look at the two different sprinkler heads located in the same smoke compartment and staff D stated they will get it corrected.

Based on observation and interview the facility failed to ensure liquid oxygen was properly secured as required in NFPA 99, 2012 Edition.

Findings:

On 02/21/20 at 11:32 am the surveyor observed the facility medical gas storage area to have six liquid oxygen tanks not secured. Four of the liquid oxygen tanks were in use and two of the liquid oxygen tanks were empty and not in use.

On 02/21/20 at 11:33 am the surveyor asked Staff D why the medical gas storage liquid oxygen tanks were not secured. Staff D stated they believed their vendor was knowledgeable of the requirements for installing them but will check with them to get the tanks secured.