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Based on document review and staff interview it was determined the facility failed to establish and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review conducted on 02/06/18 between the hours of 9:30 a.m. and 11:30 a.m. revealed the facility failed to complete the following emergency preparedness elements:

a. Policies and procedures addressing the subsistence needs of staff and patients, whether they evacuate or shelter in place, were not available for review.

b. Policies and procedures for the use of volunteers during an emergency were not available for review.

c. Development of arrangements with other facilities was not available for review.

d. Policies and procedures for roles under a Waiver declared by the Secretary were not available for review.

e. Policies and procedures for methods of sharing information and medical documentation in the event of an evacuation to include releasing patient information, general condition, and location of patients were not available for review.

f. The facility did not conduct exercises to test the emergency plan at least annually, as the facility did not participate in a full-scale community-based exercise for the previous twelve (12) months.

2. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on document review and staff interview it was determined the facility failed to ensure fire-rated door assemblies in the means of egress were inspected and tested in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review on 02/05/18 at approximately 1:08 p.m. revealed no documentation that fire doors throughout the facility had been inspected and tested annually.

2. The above finding was verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview it was determined the facility failed to ensure hazardous areas were protected and separated from other spaces in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. An observation on 02/07/18 at approximately 10:40 a.m. revealed the corridor doors separating the garage area from the kitchen corridor would not close and latch when the hold open was released.

2. An observation on 02/07/18 at approximately 10:50 a.m. revealed the kitchen corridor door near the dry storage area would not close and latch when the hold open was released.

3. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on document review, observation and staff interview it was determined the facility failed to ensure records of system testing for the fire alarm system were readily available in accordance with National Fire Protection Association (NFPA) 72. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review on 02/05/18 at approximately 1:24 p.m. revealed no documentation of smoke detector sensitivity testing for the previous two (2) years for the facility.

2. Observation and document review on 02/06/18 at approximately 8:45 a.m. revealed a damper in the basement 100 wing smoke barrier, above the ceiling, which had no documentation of inspection or testing.

3. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview it was determined the facility failed to ensure it was protected throughout by an approved automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. An observation on 02/06/18 at approximately 1:02 p.m. revealed a sprinkler head in the Outpatient Physical Therapy Modality Room closet, which was located approximately five (5) inches away from a light fixture and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

2. Observation on 02/06/18 at approximately 1:40 p.m. revealed approximately fourteen (14) sprinkler heads in the Boiler Room, which were located approximately six (6) inches away from a light fixture and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

3. An observation on 02/06/18 at approximately 2:35 p.m. revealed approximately six (6) sprinkler heads in the patient restrooms on the Rehabilitation 400 Wing, which were located approximately eleven (11) inches away from a light fixture and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

4. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview it was determined the facility failed to ensure automatic sprinkler and standpipe systems were maintained in accordance with National Fire Protection Association (NFPA) 25. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. An observation on 02/06/18 at approximately 12:42 p.m. revealed a bundle of IT wiring laying on the main sprinkler line above the basement 400 wing corridor and ran the length of the main sprinkler line from room B-54 through room B-48.

2. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on document review and staff interview it was determined the facility failed to ensure fire drills were held at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review on 02/05/18 at approximately 2:07 p.m. revealed the facility failed to record a fire drill during the second shift of the fourth quarter of 2017.

2. The above finding was verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on document review and staff interview it was determined the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review on 02/05/18 at approximately 3:42 p.m. revealed no documentation for testing of the physical integrity, continuity of the grounding circuit, correct polarity of the hot and neutral connections, or the retention force of the grounding blade for each electrical receptacle at the patient bed locations in the facility.

2. The above finding was verified with Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on observation, document review and staff interview it was determined the facility failed to ensure maintenance and testing of the generator and transfer switches was performed in accordance with National Fire Protection Association (NFPA) 110. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review on 02/05/18 at approximately 2:38 p.m. revealed no documentation the generator had been exercised under load to meet monthly required load testing, or that in lieu of the monthly required load testing, the generator had been exercised under load annually for 1.5 hours.

2. Document review on 02/05/18 at approximately 2:45 p.m. revealed no documentation the generator had been exercised for four (4) continuous hours within the last thirty six (36) months.

3. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.

Based on document review and staff interview it was determined the facility failed to ensure personnel had received the appropriate medical gas equipment qualifications and training in accordance with National Fire Protection Association (NFPA) 99. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 13.

Findings include:

1. Document review on 02/07/18 at approximately 1:00 p.m. revealed no documentation that staff had been trained on the risk of handling oxygen cylinders.

2. Document review on 02/07/18 at approximately 1:15 p.m. revealed the facility failed to provide continuing education to all staff that handle oxygen cylinders.

3. The above findings were verified with the Plant Operations Director at the time of discovery and again with the Administrator at the time of exit.