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Based on record review and interview, the facility failed develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

The finding included:

Record review on 11/6/18 at 11:00 AM, revealed the facility's all hazard risk assessment was last updated in 2011. The facility could not initially locate many portions of their emergency plan. Interview the the safety director revealed that the facility's complete emergency plan was online but had not been put together and placed in the emergency preparedness book. At the conclusion of the emergency preparedness survey, a comprehensive emergency preparedness plan was not provided for review.

This finding was verified by the safety director during record review and was acknowledged by the administrator during the exit conference on 11/6/18.

Based on observations, the facility failed to maintain the exit signage.

The findings included:

1. Observation on 11/6/18 at 10:45 AM, revealed the exit sign located by room 202 and the exit sign located above the fire doors by the Dr. lounge were obstructed by cameras.
NFPA 101, 19.2.10.1 (2012 Ed), NFPA 101, 7.10.1.8 (2012 Ed)

2. Observation on 11/6/18 at 11: 15 AM, revealed the exit sign located in the south stairway was not illuminated.
NFPA 101, 19.2.10.1 (2012 Ed), NFPA 101, 7.10.5.1 (2012 Ed)

This finding was verified by the maintenance supervisor during the survey and was acknowledged by the administrator during the exit conference on 11/6/18.

Based on observations, the facility failed to maintain the hazardous areas.

The finding included:

Observation on 11/6/18 at 11:45 PM, revealed the records storage room door that opens into the lobby was not equipped with a self closing device.
NFPA 101, 19.3.2.1.3 (2012 Ed)

This finding was verified by the maintenance supervisor during the survey and was acknowledged by the administrator during the exit conference on 11/6/18.

Based on observations, the facility failed to maintain the corridor doors.

The finding included:

Observation on 11/6/18 at 10:10 AM, revealed the x-ray room door that opens to the corridor was equipped with a roller latch.
NFPA 101, 19.3.6.3.5 (2) (2012 Ed).

This finding was verified by the maintenance supervisor during the survey and was acknowledged by the administrator during the exit conference on 11/6/18.

Based on observations, the facility failed to prohibit portable space heaters.

The finding included:

Observations on 11/6/18 between 10:20 AM and 12:00 PM, revealed portable space heaters in the following locations:

a. Doctors sleeping lounge
b. Radiology managers office
c. Radio room
d. Respiratory therapy office
NFPA 101, 19.7.8 (2012 Ed)

This finding was verified by the maintenance supervisor during the survey and was acknowledged by the administrator during the exit conference on 11/6/18.

Based on observations, the facility failed to maintain the gas equipment.

The finding included:

Observation on 11/6/18 at 11:58 AM, revealed a large oxygen/nitrogen mix cylinder in the surgery area that was not secured.
NFPA 99, 11.6.2.3 (2012 Ed)

This finding was verified by the maintenance supervisor during the survey and was acknowledged by the administrator during the exit conference on 11/6/18.