Nursing Investigation Results -

Pennsylvania Department of Health
TRANSITIONS HEALTHCARE AUTUMN GROVE CARE CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TRANSITIONS HEALTHCARE AUTUMN GROVE CARE CENTER
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
TRANSITIONS HEALTHCARE AUTUMN GROVE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 7, 2019, it was determined that Transitions Healthcare Autumn Grove Care Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(b)(2) REQUIREMENT Procedures for Tracking of Staff and Patients:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:]

(2) A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at 441.184(b), LTC at 483.73(b), ICF/IIDs at 483.475(b), PACE at 460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at 418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at 485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0018

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 May 7, 2019, at 12:35 p.m., revealed the facility lacked an emergency preparedness plan that includes tracking the location of on-duty staff and patients.

Interview with the administrator on May 7, 2019, at 12:35 p.m., confirmed the emergency preparedness plan did not include the above elements.





 Plan of Correction - To be completed: 06/21/2019

The facility will develop a written plan to track on-duty staff and residents in the event of an emergency.

The plan will be submitted to and reviewed by the Quality Assurance committee initially and then annually thereafter. Approval by the committee will be documented in the meeting minutes.


483.73(b)(3) REQUIREMENT Policies for Evac. and Primary/Alt. Comm.:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For RNHCs at 403.748(b)(3) and ASCs at 416.54(b)(2):]
Safe evacuation from the [RNHCI or ASC] which includes the following:
(i) Consideration of care needs of evacuees.
(ii) Staff responsibilities.
(iii) Transportation.
(iv) Identification of evacuation location(s).
(v) Primary and alternate means of communication with external sources of assistance.

* [For CORFs at 485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at 485.727(b)(1), and ESRD Facilities at 494.62(b)(2):]
Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients.

* [For RHCs/FQHCs at 491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0020

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 May 7, 2019, at 12:40 p.m., revealed the facility lacked an emergency preparedness plan that includes safe evacuation to include alternate communication with external sources.

Interview with the administrator on May 7, 2019, at 12:40 p.m., confirmed the emergency preparedness plan did not include the above element.





 Plan of Correction - To be completed: 06/21/2019

The facility will develop a written plan for alternate communication with external sources during an evacuation.

The plan will be submitted to and reviewed by the Quality Assurance committee initially and then annually thereafter. Approval by the committee will be documented in the meeting minutes.


483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

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 May 7, 2019, at 12:45 p.m., revealed the facility lacked an emergency preparedness plan that includes sharing plan information with residents' families or representatives.

Interview with the administrator on May 7, 2019, at 12:45 p.m., confirmed the emergency preparedness plan did not include the above element.




 Plan of Correction - To be completed: 06/21/2019

The facility will develop a written plan for sharing emergency preparedness plan information with families of residents and resident representatives.

The plan will be submitted to and reviewed by the Quality Assurance committee initially and then annually thereafter. Approval by the committee will be documented in the meeting minutes.

483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041

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 May 7, 2019, at 12:50 p.m., revealed the facility lacked an emergency preparedness plan that includes fuel source documentation to state that the emergency generator fuel source to power emergency generators will be supplied to keep emergency power systems operational during the emergency.

Interview with the administrator on May 7, 2019, at 12:50 p.m., confirmed the emergency preparedness plan did not include the above element.





 Plan of Correction - To be completed: 06/21/2019

The facility generators are powered by propane fuel. In the event of an emergency involving loss of electricity, the facility's generators fully support electrical power.

The facility will develop and enter into a Memorandum of Agreement with its propane fuel provider outlining a scenario in which vendor agrees to supply additional quantities of propane fuel in the event the generators are utilized for an extended period of time, exhausting existing fuel supply, and needing additional quantities of propane fuel.

The Memorandum of Agreement will be submitted to and reviewed by the Quality Assurance committee initially and then annually thereafter. Approval by the committee will be documented in the meeting minutes.




















Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 022102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2019, it was determined that Transitions Healthcare Autumn Grove was not in compliance with the following requirements of the Life Safety Code for existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient for the emergency generator system that supplies the entire building.

Findings include:

1. Interview with maintenance supervisor on May 7, 2019, at 9:00 a.m., revealed the facility installed a new emergency generator in the fall of 2018. The facility failed to obtain approval from State Plan Review, and request an occupancy inspection from the Division of Life Safety, for the newly installed emergency generator.

Interview with the administrator on May 7, 2019, at 9:00 a.m., confirmed the newly installed emergency generator did not have approval from State Plan Review, or an occupancy from the Division of Life Safety.



 Plan of Correction - To be completed: 06/21/2019

Facility will retroactively submit the required documents and request approval from the State Plan Review for the replacement generator that was recently installed in place of an existing generator. Additionally, the facility will request an occupancy inspection from the PA Division of Life Safety.

In order to ensure this does not recur, future additions, replacements, or removal of equipment having an impact on facility operations will be submitted to State Plan Review for approval and an Occupancy visit by Life Safety.


NFPA 101 STANDARD Exit Signage:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview it was determined that the facility failed to maintain exit signage for all of the exit signage in the facility.

Findings include:

1. Document review on May 7, 2019 at 8:36 a.m., revealed the facility failed to maintain the required documentation indicating monthly inspections were completed for all exit signage.

Interview with maintenance supervisor on May 7, 2019 at 8:36 a.m., confirmed the facility failed to maintain the required documentation indicating monthly inspections were completed for all exit signage.









 Plan of Correction - To be completed: 06/21/2019

Exit signage will be inspected monthly for proper operation by the Maintenance Director/designee. Documentation will be maintained outlining date and outcome of the inspection.

The Administrator will educate the maintenance staff on the need to inspect exit signage monthly with corresponding documentation that it has been done.

Exit signage inspection will be submitted to and reviewed by the Safety Committee monthly for 3 months and then quarterly for 3 quarters to ensure the deficient practice does not recur. The review will be noted in the minutes.

NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined that the facility failed to maintain vertical openings for one of three vertical openings.

Findings include:

1. Observation on May 7, 2019 at 11:50 a.m., revealed the door to the attic stair had hardware that lacked an indication that it was "fire exit hardware".

Interview with the maintenance supervisor on May 7, 2019 at 11:50 a.m. confirmed the above stair door hardware lacked an indication that it was "fire exit hardware".



 Plan of Correction - To be completed: 06/21/2019

Fire exit hardware will be installed on the above stair door leading to the attic by the Maintenance Director/designee.

The completion of the work will be submitted to and review by the Safety Committee

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined that the facility failed to maintain areas with combustible items in two of four wings.

Findings include:

1. Observation on May 7, 2019 between 11:15 a.m. and 11:30 a.m. revealed the following storage deficiencies:

A. (11:15 a.m.) mattress storage door "A" lacked positive latching in the frame (across from room 207);
B. (11:30 a.m.) attic is used for storage (if storage is in attic, this makes for an occupied area, and there is only one exit out of the attic).

Interview with the maintenance supervisor on May 7, 2019 at 11:30 a.m. confirmed the above storage deficiencies existed.




 Plan of Correction - To be completed: 06/21/2019

The door to the mattress storage room was equipped with positive latching.

The storage items were removed from the attic.

During the monthly safety inspection, random audits of doors will be completed affirming that the doors are able to positively latch. The random audits will be accompanied by documentation of what doors were audited.

During the monthly safety inspection, the attic will be observed to ensure it is not being used for storage with corresponding documentation.

Documentation for positive latching and attic observation will be submitted to and reviewed by the Safety Committee for 3 months to ensure the deficient practice does not recur.

NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview it was determined that the facility failed to maintain cooking facilities for one of two semi-annual inspections.

Findings include:

1. Document review on May 7, 2019 at 8:42 a.m. revealed the facility lacked a second semi-annual inspection, for the kitchen suppression system within the last year (last inspection was performed October 3, 2018).

Interview with the maintenance supervisor on May 7, 2019 at 8:42 a.m. confirmed the facility was lacking a second semi-annual inspection for the kitchen suppression system.







 Plan of Correction - To be completed: 06/21/2019

The automatic suppression system in the kitchen was inspected by an outside professional.

The automatic suppression system in the kitchen will be inspected semi-annually by an outside professional.

The Administrator will educate the maintenance staff on the need to have the kitchen suppression system inspected semi-annually.

NFPA 101 STANDARD Interior Wall and Ceiling Finish:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Interior Wall and Ceiling Finish
2012 EXISTING
Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
10.2, 19.3.3.1, 19.3.3.2
Indicate flame spread rating(s). _____________________
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0331

Based on observation and interview, it was determined that the facility failed to maintain areas that the ceiling was sealed with one of one foam-type product.

Findings include:

1. Observation on May 7, 2019 between 10:30 a.m. and 10:50 a.m. revealed the facility used a foam-type product to seal ceiling penetrations at the following locations:
a. (10:30 a.m.) basement dryer room;
b. (10:35 a.m.) basement outside maintenance shop;
c. (10:50 a.m.) basement boiler room.

Facility did not provide documentation that this foam-type product used to seal ceiling penetrations is part of a UL design number that can be used within health care facilities.

Interview with the maintenance supervisor on May 7, 2019 at 10:50 a.m. confirmed the facility lacked documentation that foam used for ceiling penetrations is part of a UL design number for use in health care facilities.



 Plan of Correction - To be completed: 06/21/2019

The foam product will be removed and replaced with a joint compound at the basement dryer room, basement maintenance shop, and the basement boiler room by the Maintenance Director/designee.

Administrator will educate the Maintenance staff on the need to use a joint compound when sealing penetrations.

The Maintenance Director will submit to the Safety Committee a report regarding the replacement of the foam product with a joint compound

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined that the facility failed to maintain fire alarm system components at one of over fifty components on the fire alarm system.

Findings include:

1. Observation on May 7, 2019 at 10:55 a.m., revealed access to the fire alarm pull activation device, located outside the basement paint room, was blocked by several wood pallets.

Interview with the maintenance supervisor on May 7, 2019 at 10:55 a.m. confirmed the above fire alarm pull activation device was blocked.









 Plan of Correction - To be completed: 06/21/2019

The wooden pallets were removed from the area in front of the fire alarm pull station.

The facility acknowledges that fire alarm pull stations must be clear from storage in the area surrounding the pull station in order to provided unimpeded access.

Fire alarm pull stations access will be audited during the monthly safety inspection. The monthly safety inspection, including fire alarm pull station audit, will be submitted to and reviewed by the Safety Committee monthly for 3 months to ensure the deficient practice does not recur. The review will be noted in the minutes.


NFPA 101 STANDARD Smoke Detection:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on document review and interview it was determined that the facility failed to maintain smoke detectors for all of the battery operated smoke detectors.

Findings include:

1. Document review on May 7, 2019 at 8:53 a.m., revealed the facility had been conducting monthly inspections on all of the battery operated smoke detectors instead of the required weekly inspections.

Interview with maintenance supervisor on May 7, 2019 at 8:53 a.m., confirmed the facility had been conducting monthly inspections on all of the battery operated smoke detectors instead of the required weekly inspections.



 Plan of Correction - To be completed: 06/21/2019

Battery operated smoke detectors will be inspected weekly for proper operation by the Maintenance Director/designee. Documentation will be maintained indicating date and outcome of the inspection.

The Administrator will educate the maintenance staff on the need to inspect battery operated smoke detectors weekly with corresponding documentation that it has been done.

Battery operated smoke detector inspection will be submitted to and reviewed by the Safety Committee monthly for 3 months and then quarterly for 3 quarters to ensure the deficient practice does not recur. The review will be noted in the minutes.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation, document review, and interview it was determined that the facility failed to maintain and test the sprinkler system on one of one sprinkler system.

Findings include:

1. Document review on May 7, 2019 at 9:45 a.m., revealed that the facility could only produce documentation for three of the four required quarterly sprinkler inspections.

Interview with the maintenance supervisor on May 7, 2019 at 9:45 a.m. confirmed that the facility could only produce documentation for three of the four required quarterly sprinkler inspections.

2. Observation on May 7, 2019 at 10:41 a.m., revealed the valve on the bottom side of the fire sprinkler tank lacked electrical monitoring to the fire alarm system (tamper switch).

Interview with the maintenance supervisor on May 7, 2019 at 10:41 a.m. confirmed the above sprinkler valve was not electrically supervised into the fire alarm system.

3. Observation on May 7, 2019, at 11:45 a.m., revealed the attic fire sprinkler piping had several wires draped over the piping (located directly above the attic trusses, above the ice machine on the first floor).

Interview with the maintenance supervisor on May 7, 2019, at 11:45 a.m., confirmed the above sprinkler piping had a load of wires over the piping.

4. Observation on May 7, 2019, at 11:09 a.m., revealed the sprinkler piping near the B-hall smoke barrier had numerous wires laying on the sprinkler piping.

Interview with the maintenance supervisor on May 7, 2019 at 11:09 a.m. confirmed the above sprinkler piping had a load of wires over the sprinkler piping.

5. Observation on May 7, 2019 between 11:31 a.m., and 11:48 a.m., revealed the following rooms had both a quick response sprinkler head and a fusible link sprinkler head in the same space:
a. (11:31 a.m.) Room 305;
b. (11:32 a.m.) Room 306;
c. (11:33 a.m.) Room 308;
d. (11:46 a.m.) Room 408;
e. (11:48 a.m.) Room 412 .

Interview with the maintenance supervisor on May 7, 2019 at 11:48 a.m. confirmed the above rooms had both a quick response sprinkler head and a fusible link sprinkler head in the same space.

6. Observation on May 7, 2019, at 11:55 a.m., revealed the facility lacked extra fire sprinkler heads for every type within the facility (specifically side-wall type).

Interview with the maintenance supervisor on May 7, 2019 at 11:55 a.m. confirmed the facility lacked extra side-wall type sprinkler heads.













 Plan of Correction - To be completed: 06/21/2019

The sprinkler system will be inspected by an outside contractor quarterly. Documentation of date and outcome of the inspection will be maintained by the Maintenance Director.

Sprinkler system inspection will be submitted to and reviewed by the Safety Committee quarterly for 4 quarters to ensure the deficient practice does not recur. The review will be noted in the minutes.

The fire alarm switch (tamper switch) was installed on the sprinkler system water tank and tied into the fire alarm system by an outside professional.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview it was determined that the facility failed to maintain corridor doors at three of over twenty corridor doors.

Findings include:

1. Observations on May 7, 2019 between 10:15 a.m. and 11:15 a.m. revealed the following deficiencies:

A. (10:15 a.m.) the A/B lounge door lacked positive latching into the frame;
B. (11:05 a.m.) resident room 207 door was swelled and difficult to open and close;
C. (11:15 a.m.) room 315 door was catching on the floor and was difficult to close.

Interview with the maintenance supervisor on May 7, 2019 at 11:15 a.m. confirmed the above deficiencies existed.







 Plan of Correction - To be completed: 06/21/2019

Corridor doors will be maintained in working order by the Maintenance staff.

The door to the A/B lounge was repaired by the Maintenance Director so that it positive latches.
The door to Room 207 was repaired so that it closes effectively by the maintenance staff.
The door to Room 315 was repaired so that it closes effectively by the maintenance staff.

The Administrator educated the maintenance staff on the importance of ensuring that corridor doors close effectively and positively latch.

Corridor doors will be randomly tested for closing and latching by the Maintenance Director/designee during the monthly safety inspection. The location and function will be documented and submitted to and reviewed by the Safety Committee monthly for 3 months to ensure the issue does not recur.

NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined that the facility failed to maintain heating, ventilation, and air conditioning on one of two building levels.

Findings include:

1. Document review on May 7, 2019 at 8:45 a.m., revealed the most recent fusible-link fire damper inspection indicated that "A side" attic damper failed. The facility lacked documentation that this damper was repaired and is in working order.

Interview with maintenance supervisor on May 7, 2019 at 8:45 a.m., confirmed the facility lacked documentation that the above failed fire damper was repaired and is in working order.





 Plan of Correction - To be completed: 06/21/2019

The fire damper fusible links are tested and repaired by an outside professional.

The fire damper fusible link noted on last inspection was repaired by an outside professional.
The documentation on the repair will be submitted to and reviewed by the Safety Committee to ensure completion.

NFPA 101 STANDARD Escalators, Dumbwaiters, and Moving Walks:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Escalators, Dumbwaiters, and Moving Walks
2012 EXISTING
Escalators, dumbwaiters, and moving walks comply with the provisions of 9.4.
All existing escalators, dumbwaiters, and moving walks conform to the requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.
(Includes escalator emergency stop buttons and automatic skirt obstruction stop. For power dumbwaiters, includes hoistway door locking to keep doors closed except for floor where car is being loaded or unloaded.)
19.5.3, 9.4.2.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0532

Based on observation and interview it was determined that the facility failed to maintain the dumbwaiter for one of one dumbwaiter.

Findings include:

1. Observation on May 7, 2019 at 10:30 a.m. revealed the dumbwaiter access room in the basement was being used to store combustible material and the door was propped open.

Interview with the maintenance supervisor on May 7, 2019 at 10:30 a.m. confirmed the dumbwaiter access room in the basement was being used to store combustible material and the door was propped open.







 Plan of Correction - To be completed: 06/21/2019

The door to the dumbwaiter access room was closed and the flammable storage items were removed.

The dumbwaiter access room will be maintained with a closed door and free of storage and debris.

The Administrator will educate the maintenance staff on the need maintain the dumbwaiter access room with a closed door and free from storage and debris.

The dumbwaiter access room will be audited during monthly Safety Inspection to ensure it is maintained with a close door and free from storage and debris. The inspections will be submitted to and reviewed by the Safety Committee monthly for 3 months to ensure the practice does not recur.

NFPA 101 STANDARD Smoking Regulations:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview it was determined that the facility failed to following smoking regulations at one of five exits.

Findings include:

1. Observation on May 7, 2019 at 10:08 a.m. revealed that the garbage can near the employee entrance had cigarette butts inside with combustible waste.

Interview with the maintenance supervisor on May 7, 2019 at 10:08 a.m., confirmed the garbage can near the employee entrance had cigarette butts inside with combustible waste.




 Plan of Correction - To be completed: 06/21/2019

The cigarette butt was removed from the trash can.

Maintenance Director/designee will audit the trash can weekly for 4 weeks and then monthly for 2 months for any sign of cigarette butts in the can.

Results of the audit will be submitted to and reviewed by the Safety Committee to ensure the issue does not recur.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911
Based on observation and interview, it was determined that the facility failed to maintain electrical system requirements that are not addressed by the provided K-tags, but are deficient in one of over fifty rooms.

Findings include:

1. Observation on May 7, 2019 at 11:35 a.m., revealed the attic (near storage) had an open junction box.

Reference: NFPA 700-314.28 (c).

Interview with the maintenance supervisor on May 7, 2019 at 11:35 a.m. confirmed the above open junction box.


 Plan of Correction - To be completed: 06/21/2019

A cover was placed on the open junction box in the attic.

All junction boxes must be covered with no exposed conduit wires.

The Administrator will educate maintenance staff to be cognizant electrical junction boxes when making rounds and safety inspections to ensure they are not open.

Junction boxes will be added to the monthly safety inspection as an audit item, so that junction boxes remain enclosed with a cover. The junction box audits will be submitted to and reviewed by the Safety Committee for 3 month to ensure the issue does not recur.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920
Based on observation and interview, it was determined that the facility failed to maintain electrical power cords in one of over fifty rooms.

Findings include:

1. Observation on May 7, 2019 at 11:00 a.m., revealed the resident room 104 had a surge protector hanging suspended from the floor by the cords attached to it.

Interview with the maintenance supervisor on May 7, 2019 at 11:00 a.m. confirmed the above power cord deficiency.


 Plan of Correction - To be completed: 06/21/2019

The surge protector was re-hung on the wall.

The surge protectors used for resident room televisions must be hung on the wall.

Random audits to ensure surge protectors are hung from the wall will be conducted monthly for 3 months during the monthly safety inspection to ensure they remain hung on the wall. The resultsof the audits will be submitted to and reviewed by Safety Committee to ensure the issue does not recur.



Initial comments:Name: ENTRANCE - Component: 03 - Tag: 0000


Facility ID # 022102
Component 03
New Entrance

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2019, it was determined that Transitions Healthcare Autumn Grove was not in compliance with the following requirements of the Life Safety Code for existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected wood frame building, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: ENTRANCE - Component: 03 - Tag: 0100

Based on interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient for the emergency generator system that supplies the entire building.

Findings include:

1. Interview with maintenance supervisor on May 7, 2019, at 9:00 a.m., revealed the facility installed a new emergency generator in the fall of 2018. The facility failed to obtain approval from State Plan Review, and request an occupancy inspection from the Division of Life Safety, for the newly installed emergency generator.

Interview with the administrator on May 7, 2019, at 9:00 a.m., confirmed the newly installed emergency generator did not have approval from State Plan Review, or an occupancy from the Division of Life Safety.



 Plan of Correction - To be completed: 06/21/2019

Facility will retroactively submit the required documents and request approval from the State Plan Review for the generator that was recently installed and replaced an existing generator. Additionally, the facility will request an occupancy inspection from the PA Division of Life Safety.

In order to ensure this does not recur, future additions, replacements, or removal of equipment having an impact on facility operations will be submitted to State Plan Review for approval and an Occupancy visit by Life Safety.


NFPA 101 STANDARD Exit Signage:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: ENTRANCE - Component: 03 - Tag: 0293

Based on document review and interview it was determined that the facility failed to maintain exit signage for all of the exit signage in the facility.

Findings include:

1. Document review on May 7, 2019 at 8:36 a.m., revealed the facility failed to maintain the required documentation indicating monthly inspections were completed for all exit signage.

Interview with maintenance supervisor on May 7, 2019 at 8:36 a.m., confirmed the facility failed to maintain the required documentation indicating monthly inspections were completed for all exit signage.







 Plan of Correction - To be completed: 06/21/2019

Exit signage will be inspected monthly for proper operation by the Maintenance Director/designee. Documentation will be maintained outlining date and outcome of the inspection.

The Administrator will educate the maintenance staff on the need to inspect exit signage monthly with corresponding documentation that it has been done.

Exit signage inspection will be submitted to and reviewed by the Safety Committee monthly for 3 months and then quarterly for 3 quarters to ensure the deficient practice does not recur. The review will be noted in the minutes.

NFPA 101 STANDARD Smoke Detection:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: ENTRANCE - Component: 03 - Tag: 0347

Based on document review and interview it was determined that the facility failed to maintain smoke detectors for all of the battery operated smoke detectors.

Findings include:

1. Document review on May 7, 2019 at 8:53 a.m., revealed the facility had been conducting monthly inspections on all of the battery operated smoke detectors instead of the required weekly inspections.

Interview with maintenance supervisor on May 7, 2019 at 8:53 a.m., confirmed the facility had been conducting monthly inspections on all of the battery operated smoke detectors instead of the required weekly inspections.




 Plan of Correction - To be completed: 06/21/2019

Battery operated smoke detectors will be inspected weekly for proper operation. Documentation will be maintained indicating date and outcome of the inspection by the Maintenance Director/designee.

The Administrator will educate the maintenance staff on the need to inspect battery operated smoke detectors weekly with corresponding documentation that it has been done.

Battery operated smoke detector inspection will be submitted to and reviewed by the Safety Committee monthly for 3 months and then quarterly for 3 quarters to ensure the deficient practice does not recur. The review will be noted in the minutes.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: ENTRANCE - Component: 03 - Tag: 0353

Based on observation, document review, and interview it was determined that the facility failed to maintain and test the sprinkler system on one of one sprinkler system.

Findings include:

1. Document review on May 7, 2019 at 9:45 a.m., revealed that the facility could only produce documentation for three of the four required quarterly sprinkler inspections.

Interview with the maintenance supervisor on May 7, 2019 at 9:45 a.m. confirmed that the facility could only produce documentation for three of the four required quarterly sprinkler inspections.

2. Observation on May 7, 2019 at 10:41 a.m., revealed the valve on the bottom side of the fire sprinkler tank lacked electrical monitoring to the fire alarm system (tamper switch).

Interview with the maintenance supervisor on May 7, 2019 at 10:41 a.m. confirmed the above sprinkler valve was not electrically supervised into the fire alarm system.








 Plan of Correction - To be completed: 06/21/2019

The sprinkler system will be inspected by an outside contractor quarterly. Documentation of date and outcome of the inspection will be maintained.

The Administrator will educate the maintenance staff on the need to inspect exit signage monthly with corresponding documentation that it has been done.
Sprinkler system inspection will be submitted to and reviewed by the Safety Committee quarterly for 4 quarters to ensure the deficient practice does not recur. The review will be noted in the minutes.

The fire alarm switch (tamper switch) was installed on the sprinkler system water tank by an outside professional and tied into the fire alarm system.

The fusible link sprinkler heads will be replaced with quick response sprinkler heads by an outside professional so that sprinkler head types all match in the same space.

Spare sprinkler heads for every type of head used in the facility will be maintained in the maintenance shop by the Maintenance Director/designee.


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