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Based on documentation review and interview, it was determined the facility failed to provide a plan to shelter in place.

Findings include:

1. Review of documentation on December 18, 2019, at 1:30 p.m., revealed the facility lacked a plan to shelter in place.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of documentation.

Based on documentation review and interview, it was determined the facility failed to provide a plan for arrangements with other facilities, including transfer agreements.

Findings include:

1. Review of documentation on December 18, 2019, at 1:30 p.m., revealed the facility lacked a plan for arrangements with other facilities.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of documentation.

Based on documentation review and interview, it was determined the facility failed to provide documentation for the role of the facility under a waiver declared by the Secretary of the Department of Health.

Findings include:

1. Review of documentation on December 18, 2019, at 1:30 p.m., revealed the facility did not provide documentation for the role of the facility under a waiver declared by the Secretary of the Department of Health.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of documentation.

Based on documentation review and interview, it was determined the facility failed to provide a plan, to provide information about the facility's occupancy needs and its ability to provide assistance to the Authority Having Jurisdiction.

Findings include:

1. Review of documentation on December 18, 2019, at 1:30 p.m., revealed the facility lacked a plan to provide a plan, to provide information about the facility's occupancy needs and its ability to provide assistance to the AHJ.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of documentation.

Based on observation and interview, the means of egress was not free from all obstructions, affecting one of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, at 8:15 a.m., revealed a reclining chair placed in the corridor near resident room #2050.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the egress obstruction.

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, affecting one of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, at 8:15 a.m., revealed the 1st floor lab storage room door lacked a self-closing device.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain exit discharges, affecting two of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, at 10:05 a.m., revealed the exit discharge located outside the Phase III hall did not lead occupants safely to the public way due to uneven ground covered with snow and ice.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the exit discharge.

Based on observation and interview, it was determined the facility failed to maintain exit signs, affecting two of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, at 11:15 a.m., revealed the lack of exit signs located above both sides of the 1st floor, cross-corridor smoke barrier doors #1742.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of exit signs.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting one of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, at 10:30 a.m., revealed the outside dock, used for equipment storage, etc., lacked sprinkler coverage.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of sprinkler coverage.

Based on observation and interview, it was determined the facility failed to maintain sprinkler systems, affecting two of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, between 9:00 a.m. and 10:15 a.m., revealed:

a. 9:00 a.m.- The 1st floor IT room had ceiling tiles out of place which would delay the sprinkler activation if needed.

b. 10:15 a.m. - The Lower Level had wires attached to sprinkler piping located near the cross-corridor doors #022.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of tiles and wires attached to the sprinkler piping.

Based on documentation review and interview, it was determined the facility failed to provide the annual inspection of all fire rated doors, affecting nine of nine smoke compartments.

Findings include:

1. Review of documentation on December 19, 2019, at 7:40 a.m., revealed the facility failed to perform a required annual fire door inspection.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of a door inspection.

Based on observation and interview, it was determined the facility failed to maintain emergency generators, affecting the entire facility.

Findings include:

1. Observation on December 19, 2019, at 7:50 a.m., revealed the facility lacked an externally located emergency stop for the generator.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the lack of an externally located emergency stop.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, affecting two of nine smoke compartments.

Findings include:

1. Observation on December 19, 2019, at 8:16 a.m., revealed the 1st floor lab breakroom had a crock pot and coffee pot plugged into an unauthorized surge power strip.

Exit interview with facility representatives #1 and #2 on December 19, 2019, at 11:15 a.m., confirmed the use of a surge power strip.