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Based on document review and staff interview it was determined the facility failed to provide policies and procedures that address the role of the facility under waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. Failure to have policies or procedures regarding the provision of care and treatment, at an alternate care site identified by emergency management officials, has the potential to negatively impact all patients.

Findings include:

1. Document review revealed the facility failed to provide Emergency Preparedness policies and procedures that address the role of the facility under waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Emergency Management Manager and the Chief Nursing Officer.

Based on document review and staff interview it was determined the facility failed to provide a documented emergency preparedness training and testing program that is based on the emergency plan, the risk assessment and the communication plan in accordance with all applicable Federal, State, and local emergency preparedness requirements. Failure to have a documented emergency preparedness training and testing program has the potential to negatively impact all patients.

Findings include:

1. Document review revealed the facility failed to provide a documented emergency preparedness training and testing program based on the emergency plan, the risk assessment and the communication plan in accordance with applicable Federal, State, and local emergency preparedness requirements.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Emergency Preparedness Manager and the Chief Nursing Officer.

Based on document review and staff interview it was determined the facility failed to meet the requirement of an emergency preparedness training program including initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Failure to meet the requirements of an emergency preparedness training program has the potential to negatively impact all patients.

Findings include:

1. Document review revealed the facility failed to meet the requirement of an emergency preparedness training program including initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Emergency Preparedness Manager and the Chief Nursing Officer.

Based on document review and staff interview it was determined the facility failed to conduct an annual test on emergency lighting in accordance with National Fire Protection Association (NFPA) 101. Facility census 6.

Findings include:

1. Document review revealed the facility failed to conduct an annual test on emergency lighting in accordance with NFPA 101.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Safety Officer and the Chief Nursing Officer.

Based on observation and staff interview it was determined the facility failed to protect hazardous areas in accordance with National Fire Protection Association (NFPA) 101. Facility census 6.

Findings include

1. A facility inspection tour conducted on 05/15/18 between the hours of 8:30 a.m. and 1:30 p.m. revealed the door to the kitchen dish washer room was missing a door closure, the door to the kitchen closet was missing a door closure and the door to the linen storage room was missing a door closure, putting the facility in non-compliance with NFPA 101.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Safety Officer and the Chief Nursing Officer.

Based on observation and staff interview it was determined the facility failed to conduct inspections on fire dampers in accordance with National Fire Protection Association (NFPA) 101. Facility census 6.

Findings include:

1. A facility inspection tour conducted on 05/15/18 between the hours of 8:30 a.m. and 1:30 p.m. revealed the facility failed to inspect fire dampers in accordance with the requirements of NFPA 101.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Safety Officer and the Chief Nursing Officer.

Based on document review and staff interview it was determined the facility failed to conduct fire drills at expected and unexpected times under varying conditions, at least quarterly each shift, in accordance with National Fire Protection Association (NFPA) 101.

Findings include:

1. Document review revealed the facility conducted fire drills the first quarter day shift on 01/29/18 at 8:20 a.m., the 2nd quarter day shift on 04/29/18 at 8:10 a.m., the first quarter evening shift on 02/22/18 at 3:50 p.m. and the 2nd quarter evening shift on 05/30/17 at 3:30 p.m., putting the facility in non-compliance with NFPA 101.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Safety Officer and the Chief Nursing Officer.

Based on document review and staff interview it was determined the facility failed to conduct electrical inspections of receptacles at the patient bed location in accordance with National Fire Protection Association (NFPA) 99. Facility census 6.

Findings include:

1. Document review revealed the facility failed to conduct electrical inspections of receptacles at patient bed locations in accordance with NFPA 99.

2. The above finding was confirmed on 05/15/18 at approximately 1:30 p.m. with the Safety Officer and the Chief Nursing Officer.