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Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:00 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes persons at risk.

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:00 a.m., confirmed the Emergency Preparedness Plan did not include the above element.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:30 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes:
a. Subsistence needs for staff and patients (including safe storage of food, water, medical supplies and pharmaceuticals)
b. Sustainable power during an emergency
c. Alternate power sources
d. Maintenance of building temperatures
e. Fire detection, extinguishing and alarm systems
f. Sewage and waste disposal

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:30
a. m., confirmed the Emergency Preparedness Plan did not include the above elements.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:05 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes tracking the location of on-duty staff and patients.

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:05
a. m., confirmed the Emergency Preparedness Plan did not include the above element.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:07 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes safe evacuation to include:
a. Care and treatment of evacuees
b. Staff responsibilities
c. Transportation
d. Identification evacuation locations

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:07
a. m., confirmed the Emergency Preparedness Plan did not include the above elements.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:10 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes system for medical documentation to include:
a. Preserve patient information
b. Protect confidentially
c. Secures and maintains available records

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:10
a. m., confirmed the Emergency Preparedness Plan did not include the above elements.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:15 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes a communication plan that complies with Federal, State and Local laws (including names and contact information for staff, patients, physicians, other facilities, suppliers, the sharing of patent information, continuity of patient care and volunteers).

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:15
a. m., confirmed the Emergency Preparedness Plan did not include the above elements.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:20 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes facility occupancy type information to the Authority Having Jurisdiction.

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:20
a. m., confirmed the Emergency Preparedness Plan did not include the above element.

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 9, 2018, at 11:25 a. m., revealed the facility lacked an Emergency Preparedness Plan that includes an initial training on Emergency Management for individuals providing services (including volunteers). If volunteers are not used, facility shall document this fact.

Interview with the Safety Officer and the Maintenance Director on April 9, 2018, at 11:25
a. m., confirmed the Emergency Preparedness Plan did not include the above elements.

Based on observation and interview, the facility failed to maintain horizontal exit door components at one of four building levels.

Findings include:

1. Observation on April 10, 2018, between 9:05 a.m. and 9:50 a.m., revealed the following horizontal exit fire door components did not meet regulations:
a. (9:05 a.m.) Level 0 fire door frame, near "blue elevator" (between 1963 building and Patient Tower building), lacked a fire rated label.
b. (9:50 a.m.) Level 0 fire doors, closest to stair tower tower #10, lacked positive latching with the coordinator.

Interview with the Maintenance Director on April 10, 2018, at 9:50 a.m., confirmed the above horizontal exit fire door component deficiencies.

Based on observation and interview, the facility failed to maintain discharge from exits at one of three outside exits.

Findings include:

1. Observation on April 10, 2018, at 8:55 a. m., revealed the ground floor, exit discharge steps, from the ground floor, Maintenance/Bio-med corridor, to a public way, are cracked and broken. The steps do not provide a level walking surface.

Interview with the Maintenance Director on April 10, 2018, at 8:55 a. m., confirmed the above exit discharge deficiency.

Based on observation and interview, the facility failed to maintain illumination of means of egress at one of four exits.

Findings include:

1. Observation on April 10, 2018, between 10:05 a.m. and 10:10 a.m., revealed the following means of egress lighting can be turned off by a light switch, leaving the area in total darkness:
a. (10:05 a.m.) Level 0, M. R. I. exit #12
b. (10:10 a.m.) Level 0, Old C. T. ramp exit #13

Interview with the Maintenance Director on April 10, 2018, at 10:10 a.m., confirmed the above means of egress areas are not illuminated in accordance with regulations.

Based on document review and interview, the facility failed to maintain emergency lighting at two of two emergency generator locations.

Findings include:

1. Document review on April 9, 2018, at 8:10 a.m., revealed the facility lacked documentation that testing of the emergency battery-pack lighting, at both emergency generator locations, was performed within the last year:
a. Annual 90 minute drain test
b. Monthly 30 second function test

Interview with the Maintenance Director on April 9, 2018, at 8:10 a.m., confirmed the emergency lighting documentation was unavailable during the time of the survey.

Based on document review and interview, the facility failed to maintain exit signage during five of twelve months, within the last year.

Findings include:

1. Document review on April 9, 2018, at 8:20 a. m., revealed the facility lacked documentation, that a monthly inspection of the exit signs, throughout the building was performed, during the months of February, March, May, September, and December, within the last year.

Interview with the Maintenance Director on April 9, 2018, at 8:20 a. m., confirmed the above exit sign documentation was unavailable during the time of the survey.

Based on document review, observation and interview, the facility failed to maintain exit signage in all areas of the building.

Findings include:

1. Document review on April 9, 2018, at 8:20 a.m., revealed the facility lacked documentation that a monthly inspection of the exit signs throughout the building was performed during the months of February, March, May, September, and December, within the last year.

Interview with the Maintenance Director on April 9, 2018, at 8:20 a.m., confirmed the above exit sign documentation was unavailable during the time of the survey.

2. Observation on April 10, 2018, between 10:10 a.m., and 10:20 a.m., revealed the following exit signs were not illuminated:
a. (10:10 a.m.) Level 0, Old C. T. ramp (two signs total)
b. (10:20 a.m.) Level 2, sign above stair tower #10

Interview with the Maintenance Director of April 10, 2018, at 10:20 a.m., confirmed the above exit signs were not illuminated.

Based on observation and interview, the facility failed to maintain vertical openings at one of two exit stair towers.

Findings include:

1. Observation on April 10, 2018, between 8:45 a. m. and 8:50 a. m., revealed the following stair tower fire door components, did not meet regulations:
a. (8:45 a. m.) Two fire door frames lacked labels to indicate a fire rating at the ground floor stair tower, near the Comm-center (frames in both sets of double doors, two frames total).
b. (8:50 a. m.) Fire door hardware lacked an indication that it was "fire exit hardware" at the ground floor stair tower, between Registration and Level 0, to Annex Patient Tower.

Interview with the Maintenance Director on April 10, 2018, at 8:50 a. m., confirmed the above stair tower fire door component deficiencies.

Based on observation and interview, the facility failed to maintain vertical openings at three of four building levels.

Findings include:

1. Observation on April 10, 2018, between 9:03 a.m. and 11:07 a.m., revealed the following stair tower fire door components did not meet regulations:
a. (9:03 a.m.) Level 0, stair door to the basement, lacked positive latching
b. (9:45 a.m.) Level 0, stair #8 door frame, lacked a fire rated label
c. (9:55 a.m.) Level 0, stair #10 door frame, lacked a fire rated label
d. (10:17 a.m.) Level 0, stair #11 door hardware, is not "fire exit hardware" (listed as "panic hardware")
e. (10:18 a.m.) Level 0, stair #11 door frame, lacked a fire rated label
f. (10:25 a.m.) Level 2, stair #10 door labels, are painted on both doors, and illegible
g. (10:26 a.m.) Level 2, stair #10 double doors, lacked positive latching
h. (10:30 a.m.) Level 2, stair #8 door frame, lacked a fire rated label
i. (10:45 a.m.) Level 1, stair 1104 Short Stay suite, door frame lacked a fire rated label
j. (10:50 a.m.) Level 1, stair outside of Short Stay suite, door frame lacked a fire rated label
k. (10:51 a.m.) Level 1, stair outside of Short Stay suite, double doors lacked positive latching with the coordinator
l. (11:05 a m.) Level 1, stair #11 door frame, lacked a fire rated label
m. (11:07 a.m.) Level 1, stair #11 door, lacked positive latching

Interview with the Maintenance Director on April 10, 2018, at 11:07 a.m., confirmed the above stair tower fire door component deficiencies.

Based on observation and interview, the facility failed to maintain hazardous area door components at two of four building levels.

Findings include:

1. Observation on April 10, 2018, between 10:00 a.m., and 11:00 a.m., revealed the following hazardous area fire door components did not meet regulations in a partially sprinklered building:
a. (10:00 a.m.) Level 0, elevator equipment room door hardware did not indicate that it was "fire exit hardware".
b. (11:00 a.m.) Level 1, Laboratory storage room door, and door frame, lacked fire rated labels.

Interview with the Maintenance Director on April 10, 2018, at 11:00 a.m., confirmed the above hazardous area fire door component deficiencies.

Based on document review, observation, and interview, the facility failed to maintain kitchen cooking equipment for one of one kitchen.

Findings include:

1. Document review on April 9, 2018, at 8:00 a. m., revealed the facility lacked documentation that the first floor kitchen hood suppression system had semi-annual cleaning performed within the last year.

Interview with the Maintenance Director on April 9, 2018, at 8:00 a. m., confirmed the hood cleaning documentation was unavailable during the time of the survey.


2. Observation on April 9, 2018, at 10:30 a. m., revealed the first floor kitchen lacked signage at all Class K fire extinguisher locations stating, "The fire protection system shall be activated prior to using the fire extinguisher."

Interview with the Maintenance Director on April 9, 2018, at 10:30 a. m., confirmed the lack of signage for class K fire extinguishers.

Based on observation and interview, the facility failed to maintain the sprinkler system installation on three of six building levels.

Findings include:

1. Observation on April 9, 2018, between 10:25 a. m., and 12:40 p. m. revealed the following closets lacked fire sprinkler coverage:
a. (10:25 a. m.) Second floor, Human Resource closets, near both reception desks (two total)
b. (12:40 p. m.) First floor, data closet, across from 1215 Materials Management

Interview with the Maintenance Director on April 9, 2018, at 12:40 p. m., confirmed the above closets lacked fire sprinkler coverage.

2. Observation on April 10, 2018, at 8:40 a. m., revealed the ground floor, Registration area break room closet, lacked fire sprinkler coverage.

Interview with the Maintenance Director on April 10, 2018, at 8:40 a. m., confirmed the above closet lacked fire sprinkler coverage.

Based on observation and interview, the facility failed to maintain sprinkler systems on one of four building levels.

Findings include:

1. Observation on April 10, 2018, at 9:00 a.m., revealed Basement "Old Boiler" Light Bulb room, had a large amount of ceiling tile removed. This condition may delay the activation of the fire sprinkler heads within this room.

Interview with the Maintenance Director on April 10, 2018, at 9:00 a.m., confirmed the above sprinkler deficiency.

Based on observation and interview, the facility failed to maintain sprinkler systems on one of six building levels.

Findings include:

1. Observation on April 9, 2018, at 9:30 a. m., revealed the fourth floor corridor (above the ceiling tile near West Housekeeping closet), had a large load of data wires laying on top of the fire sprinkler pipe.

Interview with the Maintenance Director on April 9, 2018, at 9:30 a. m., confirmed the above sprinkler deficiency.

Based on observation and interview, the facility failed to maintain portable fire extinguishers at two of over twenty fire extinguishers.

Findings include:

1. Observation on April 10, 2018, between 10:15 a.m., and 10:55 a.m., revealed the following portable fire extinguishers were not properly mounted:
a. (10:15 a. m.) Level 0, M. R. I. waiting, near exit #12
b. (10:55 a. m.) Level 1, Laboratory

Interview with the Maintenance Director of April 10, 2018, at 10:55 a.m., confirmed the above fire extinguishers were not properly mounted.

Based on observation and interview, the facility failed to maintain corridor doors for one of over fifty corridor doors.

Findings include:

1. Observation on April 10, 2018, at 9:30 a.m., revealed the back door to Level 0, Housekeeping, lacked positive latching with the self-closure.

Interview with the Maintenance Director on April 10, 2018, at 9:30 a.m., confirmed the above corridor door lacked positive latching.

Based on observation and interview, the facility failed to maintain corridor doors in one of over ten smoke compartments.

Findings include:

1. Observation on April 9, 2018, at 12:45 p.m., revealed the first floor, Clean Linen room double doors 1207, lacked positive latching in the frame.

Interview with the Maintenance Director on April 9, 2018, at 12:45 p.m., confirmed the above corridor doors lacked positive latching in the frame.

Based on document review and interview, the facility failed to maintain gas and vacuum piped in systems for one of one medical gas system.

Findings include:

1. Document review on April 9, 2018, at 8:30 a.m., revealed the last medical gas alarm panel testing (November 6, 2017) revealed deficiencies in the following areas:
a. Area alarm
b. Zone shut-off valves
c. Outlets/inlets
d. Central supply

Interview with the Maintenance Director on April 9, 2018, at 8:30 a.m., confirmed the above medical gas deficiencies on the annual testing report.

Based on observation and interview, the facility failed to maintain electrical systems in wet locations on one of six building levels.

Findings include:

1. Observation on April 9, 2018, at 9:05 a.m., revealed the fourth floor, East Therapy janitor closet 4435, had a hydrocollator that was not plugged into a ground-fault circuit interrupter.

Interview with the Maintenance Director on April 9, 2018, at 9:05 a.m., confirmed the above electrical deficiency.

Based on observation and interview, the facility failed to maintain power and extension cords on one of four building levels.

Findings include:

1. Observation on April 10, 2018, at 10:35 a.m., revealed Level 1, Short Stay nurses station, had a portable heater plugged into a surge protector.

Interview with the Maintenance Director on April 10, 2018, at 10:35 a.m., confirmed the above electrical deficiency.

Based on observation and interview, the facility failed to maintain power and extension cords on three of six building levels.

Findings include:

1. Observation on April 9, 2018, between 9:50 a.m., and 10:20 a.m. revealed the following electrical deficiencies:
a. (9:50 a.m.) Third floor, Employee Conference room, had an extension cord in the data closet.
b. (9:55 a.m.) Third floor, Lounge, had an extension cord for the television stand.
c. (10:20 a.m.) Second floor, Human Resources room 2204, had a portable heater plugged into a surge protector.

Interview with the Maintenance Director on April 9, 2018, at 10:20 a.m., confirmed the above electrical deficiencies.

2. Observation on April 10, 2018, at 8:35 a.m., revealed the ground floor, Main Server room, had an extension cord for a fan.

Interview with the Maintenance Director on April 10, 2018, at 8:35 a.m., confirmed the above electrical deficiency.