Nursing Investigation Results -

Pennsylvania Department of Health
FAIR ACRES GERIATRIC CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FAIR ACRES GERIATRIC CENTER
Inspection Results For:

There are  36 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.
FAIR ACRES GERIATRIC 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 13-14, 2019, it was determined that Fair Acres Geriatric 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(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, it was determined the facility failed to develop an Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives, affecting the entire facility.

Findings include:

1. Document review on May 13, 2019, at 8:00 am, revealed the facility lacked a written Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 06/30/2019

A Emergency Flyer was created to inform families of facility emergency plan. Emergency Flyer will be placed in all new admission agreements, hung on all floors and mailed out with our yearly family notification mailing.

Administrator designee will ensure that all flyers are put in the spots mentioned above. Quarterly checks will be completed to ensure preparedness plan
is continually available for family viewing.
483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to conduct 1 of 2 required annual exercises to test the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on May 13, 2019, at 8:00 am, revealed within the previous 12 months, the facility only preformed a full scale exercise and did not perform the additional required exercise to test the facility's emergency preparedness plan.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the documentation was not available for a second exercise.





 Plan of Correction - To be completed: 06/20/2019

A new full scale exercise was performed.
After the exercise was completed a tabletop discussion was completed. The tabletop comprised of members or designees of the Emergency team to discuss how the drill went and what needed to be adjusted. Questions were answered and discussed among the team.

Emergency Team leaders were in-serviced on that after a full scale exercise is completed a tabletop discussion must occur to go over the pros and cons of the drill and how to improve.

All exercises and table top discussions will be kept in a book for record keeping. Fire and Safety Director or designee will maintain book to ensure tabletop discussions are completed.
Initial comments:Name: BLDG. 1 - Component: 01 - Tag: 0000


Facility ID #061002
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on May 13-14, 2019, at Fair Acres Building 1, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an 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 III (200) unprotected ordinary building, with a basement, that is fully sprinklered.








 Plan of Correction:


NFPA 101 STANDARD Corridor - Doors: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.
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: BLDG. 1 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure there were no impediments to the closing of the corridor doors, and ensure the corridor doors positively latched into the door frame, affecting two of four smoke compartments within this component.

Findings include:

1. Observation made on May 14, 2019, at 9:35 am, revealed that nurses station corridor door rubs on the floor when placed in the close position.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the door was impeded from closing.

2. Observation made on May 14, 2019, at 9:20 am, revealed that resident dining room double doors failed to close completely and positively latch into the door frame.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the doors failed to latch.










 Plan of Correction - To be completed: 07/13/2019

K 0363
1. The nurses station corridor door that was revealed rubs on the floor when in a closed position will be repaired so that the door in a closed position does not rub on the floor. This nurses station door will be inspected/audited monthly by a maintenance department designee to ensure that the door does not rub on the floor when in a closed position for one quarter. Additionally, a monthly preventative maintenance inspection/audit will be performed to ensure a duplication of this problem does not reoccur.
2. The resident dining room double doors that was revealed failed to close completely and positively latch into the door frame will be repaired so that the doors close completely and latches positively within its frame. These resident dining room double doors will be inspected/audited monthly by a maintenance department designee to ensure that the door closes and latches positively for one quarter. Additionally, a monthly preventative maintenance inspection/audit will be performed to ensure a duplication of this problem does not reoccur.



NFPA 101 STANDARD Electrical Systems - Other: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.
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: BLDG. 1 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two levels within this component.

Findings include:

1. Observation made on May 14, 2019, at 9:55 am, revealed within the basement forrest/storage room, back wall had an outlet cover plate was missing.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed missing protective cover plate.






 Plan of Correction - To be completed: 06/30/2019

K 0911
a. The outlet cover plate that was revealed missing in the forest/storage (cedar) room on the back wall will be secured with a new outlet cover. This area will be monitored monthly for one quarter to ensure that damage does not intercede in reoccurring this condition.




NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: BLDG. 1 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor electrical devices for unauthorized use, affecting one of two smoke compartments within this component.

Findings include:

1. Observation made on May 14, 2019 at 8:45 am, revealed inside room 103 B, there was a nebulizer plugged into a surge protector.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the unauthorized use of electrical device.








 Plan of Correction - To be completed: 06/17/2019

K 0920
a. The nebulizer in resident room 103b revealed that was plugged into a surge protector will be removed and plugged directly into a wall outlet. A Maintenance department designee will inspect/audit resident room 103b to ensure that all medical equipment is properly plugged directly into a wall out monthly for one quarter. In addition all nursing staff will be inserviced to insure that there isn't a reoccurrence of this deficient practice.



NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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.
Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: BLDG. 1 - Component: 01 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems affecting three of three smoke compartments within this facility.
Findings include:
1. Review of documentation on May 14, 2019, between 8:30 a.m. and 10:30 a.m., revealed the required annual inspection of receptacles in patient care areas was not performed.

Receptacle testing should include the following:
a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the test was not performed.







 Plan of Correction - To be completed: 07/13/2019

K 0921
1. The required annual inspection of receptacles in patient care areas revealed that this process had not been completed to include:

a. Resident care rooms
b. Visual inspection of physical integrity
c. Correct polarity of the hot and neutral connections
d. Retention force of the grounding blade shall not be less that 4 oz. (except locking-type receptacles
This annual inspection will be performed for this inspection as well as will continue to be an annual inspection process for the Facilities Management Department and Fair Acres. This process will commence immediately.


Initial comments:Name: BLDG. 6 - Component: 03 - Tag: 0000


Facility ID #061002
Component 03
Building 06

Based on a Medicare/Medicaid survey conducted on May 13-14, 2019, is was determined that Fair Acres - Building 06 was not in compliance with the following requirements of the Life Safety Code for an 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 three-story, Type II (222) fire resistive construction, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure exits were readily accessible at all times, affecting one of four levels within this component.

Findings include:

1. Observation made on May 13, 2019, between 9:35 am and 10:00 am, revealed the following exit discharge doors to the outside were difficult to open, at the following locations:

a. 9:35 am, ground floor Stair tower 1 by room G-10;
b. 10:00 am, ground floor horizontal exit door by the nurse supervisor office.

Interview with the Administrator and Director of Maintenance at the exit interview on May 1, 2019, at 2:20 pm, confirmed the doors required force to open.






 Plan of Correction - To be completed: 07/12/2019

K 0211
a. Where it was revealed that the ground floor stair tower 1 exit door by room G-10 that was difficult to open will be repaired so that the door opens without resistance for easy egress. This door will be monitored monthly for 1 quarter by a maintenance department designee and the results will be given to the Performance Improvement Department for review. 7/12/19
b. Where it was revealed that the ground horizontal exit door by the nurse supervisor office that was difficult to open will be repaired so that the door opens without resistance for easy egress. This door will be monitored monthly for 1 quarter by a maintenance department designee and the results will be given to the Performance Improvement Department for review.
7/12/19

NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors to stair tower enclosures, affecting two of two stair towers located within this facility component.

Findings include:

1. Observation made on May 13, 2019, between 9:30 am and 10:20 am the following stair tower doors fire resistive rating labels were missing, at the following locations:

a. 9:30 am, ground floor stair tower #1 inner door;
b. 10:20 am, basement stair tower #1 inner door.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the missing fire door resistive labels.








 Plan of Correction - To be completed: 07/13/2019

K 0223
1. The ground floor stair tower #1 inner door that revealed missing a fire resistive label will be replaced with a new stair tower door with a fire resistive label.

2. The basement stair tower #1 inner door that revealed missing a fire resistive label will be replaced with a new stair tower door with a fire resistive label.




NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair towers, in one of two stair towers within this component.

Findings include:

1. Observation on May 13, 2019, at 10:00 am, revealed, the basement mechanical room stair tower had an unsealed penetration around data cables.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the unsealed penetration of the stair tower enclosure.











 Plan of Correction - To be completed: 06/30/2019

K 0225
1. In the basement mechanical room stair tower where it was revealed an unsealed penetration will be closed using Hilti System No. W-J-1248. This condition will be monitored monthly for one quarter and results given to Performance Improvement Department for review.


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: BLDG. 6 - Component: 03 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings between floors with the required fire resistive rated construction, affecting two of four levels within this facility component.

Findings include:

1. Observation made on May 13, 2019 at 9:21 am, revealed first floor pipe shaft located across form room 103, there was an unsealed blue data wire penetration of the shaft wall.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the unsealed shaft penetration.





 Plan of Correction - To be completed: 06/30/2019

K 0311

1. Where it was revealed on the first floor pipe shaft, located across from room 103 there was an unsealed blue data wire penetration of the shaft wall will be sealed with Hiliti System No. W-J-3215 filling the area around the blue data cable to prevent the passage of smoke. This pipe chase area will be monitored/inspected monthly for one quarter to ensure that there are not any future penetrations around data wires in the pipe shaft wall to ensure a duplication of this problem does not reoccur.


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: BLDG. 6 - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to ensure doors to hazardous areas were capable of resisting the passage of smoke, on one of four levels within this component.

Findings include:

1. Observation made on May 13, 2019 at 9:15 am, revealed the first floor east soiled utility room corridor door had a gap of 1/2" between the meeting edge and door stop.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the door could not resist the passage of smoke.






 Plan of Correction - To be completed: 06/30/2019

K 0321
a. Revealed on the first floor east soiled utility room corridor door there was a " gap between the meeting edge and door stop will be closed so that there will not be any evidence of a gap and will resist the passage of smoke. This door will be inspected/audited monthly for one quarter by a maintenance department designee to ensure the door gap remains closed. Results of the audit will be given to Performance Improvement Department for review.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BLDG. 6 - Component: 03 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to ensure the automatic sprinkler system components were maintained free of corrosion, on one of three floors within this component.

Findings include:

1. Observation on May 13, 2019, at 10:20 am, revealed two sprinklers with a buildup of corrosion, on the basement loading dock.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the corrosion on the sprinklers.




 Plan of Correction - To be completed: 06/30/2019

K 0353
1. The two sprinkler's with a build-up of corrosion revealed on the basement loading dock will be replaced so that there isn't any impediment of the sprinkler's capability to perform in the recommended capacity of force and flow. A Facilities Management designee will perform a monthly preventative maintenance check for one quarter to ensure a duplication of this problem does not reoccur. The results will be sent to the Performance Improvement Department for review.



NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls, on one of three floors within this component.

Findings include:

1. Observation on May 13, 2019, at 9:50 am, revealed, above the suspended ceiling by resident room G-09, an unsealed penetration around MC and data lines.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the unsealed penetration of the corridor wall.




 Plan of Correction - To be completed: 06/30/2019

K 0362
1. The unsealed penetration revealed above the suspended ceiling by resident room G-09 will be closed using Hilti System No. W-J-1248. This condition will be monitored monthly for one quarter and results given to Performance Improvement Department for review.



NFPA 101 STANDARD Corridor - Doors: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.
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: BLDG. 6 - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch when tested, on one of three floors within this component.

Findings include:

1. Observation on May 13, 2019, at 10:15 am, revealed basement housekeeping storage room door failed to close and latch when tested due to steel wool stuffed into the latch mechanism.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the door failed to close and latch when tested.





 Plan of Correction - To be completed: 07/10/2019

K 0363
a. The basement housekeeping storage room door that revealed it failed to close and latch due to steel wool stuffed into the latch mechanism will be removed. The door will be tested to indicate the door latches properly within its frame. This door will be monitored monthly for one quarter by a maintenance department designee and the results will be given to the Performance Improvement Department for review. The housekeeping Department will be inserviced so that they are aware that nothing can be placed inside the latch mechanism impeding the positive latching of any storage door they use.




NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the building.

Findings include:

1. Observation on May 13, 2019, at 10:25 am, revealed, in the basement, all indicator lights on the generator annunciator panel were flashing continuously.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the flashing lights at the generator annunciator panel.




 Plan of Correction - To be completed: 06/24/2019

K 0920
1. All the indicator lights on the generator annunciator panel that were revealed that were flashing continuously in the basement will be addressed with our emergency generator contractor and corrected/repaired immediately. This annunciator panel is monitored monthly by our emergency generator contractor but will also for the reason for this issue will be monitored weekly by a Maintenance Department designee for one quarter so that a reoccurrence of this condition does not occur. Results of the audit will be given to Performance Improvement for review.
6/24/19



NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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 - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems, affecting three of three floors within this facility.
Findings include:
1. Review of documentation on May 14, 2019, between 8:30 a.m. and 10:30 a.m., revealed the required annual inspection of receptacles in patient care areas was not performed.

Receptacle testing should include the following:
a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the test was not performed.





 Plan of Correction - To be completed: 07/13/2019

K 0921
1. The required annual inspection of receptacles in patient care areas revealed that this process had not been completed to include:

a. Resident care rooms
b. Visual inspection of physical integrity
c. Correct polarity of the hot and neutral connections
d. Retention force of the grounding blade shall not be less that 4 oz. (except locking-type receptacles
This annual inspection will be performed for this inspection as well as will continue to be an annual inspection process for the Facilities Management Department and Fair Acres. This process will commence immediately.


Initial comments:Name: BLDG. 7 - Component: 04 - Tag: 0000


Facility ID #061002
Component 04
Building 7

Based on a Medicare/Medicaid survey conducted on May 13-14, 2019, is was determined that Fair Acres Building 7 was not in compliance with the following requirements of the Life Safety Code for an 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 III (200) unprotected ordinary building, with a basement that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: BLDG. 7 - Component: 04 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain stair tower doors, in one of two stair towers within this component.

Findings include:

1. Observation on May 13, 2019, between 1:20 pm and 1:35 pm, revealed the following stair tower door assemblies were missing a fire resistive rating labels.

a. 1:20 pm, south east stair tower door by the staff lounge;
b. 1:35 pm, south west stair tower by nurses station.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the missing fire-rating labels.


2. Observation on May 13, 2019, 2:15 pm, revealed the 1st floor south west wing stair tower door by room 307 failed to positivley latch into the frame.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the door failed to latch.




 Plan of Correction - To be completed: 07/13/2019

K 0225

Where it was revealed that door assemblies were missing fire resistive labels on the south east stair tower door by the staff lounge and the south west stair tower by nurses station will be have fire resistive labels on door assemblies and doors as prescribed by code. Facilities Manager or designee
will check doors moving forward to ensure proper labels are on all door assemblies and doors as prescribed by code.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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: BLDG. 7 - Component: 04 - Tag: 0311

Based on observation and interview, it was determined the facility failed to ensure vertical penetrations between floors maintained a fire resistance rating, affecting two of two floors within this component.

Findings include:

1. Observation on May 13, 2019, at 1:55 pm, revealed, in NE basement Insta-hot area, had several conduit penetrations of the ceiling assembly stuffed with a combustible paper product.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the improperly sealed vertical penetrations.








 Plan of Correction - To be completed: 06/30/2019

K 0311

1. The several conduit penetrations revealed in the ceiling assembly in the basement of NE near the Insta-Hot area stuffed with a combustible paper product will be rectified by: The combustible material being removed and the penetrations then sealed with Hiliti System No. W-J-3215 filling all voids in the ceiling assembly to prevent the passage of smoke. This ceiling assembly will be monitored/inspected monthly for one quarter to ensure that there are not any future penetrations in the ceiling assembly to ensure a duplication of this problem does not reoccur.

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: BLDG. 7 - Component: 04 - Tag: 0324

Based on observation, document review and interview, it was determined the facility failed to ensure Kitchen Exhaust Hood cleanings were conducted at required intervals, affecting 1 of two inspections.
Findings include:
1. Document review on May 14, 2019, between 8:30 am and 10:30 am, revealed semi-annual kitchen exhaust hood cleanings were conducted on September 13, 2018 and April 3, 2019. The facility could not produce documentation verifying hood cleanings had been performed on a semi-annual basis.
Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed a semi-annual kitchen hood cleaning had not been conducted within the required time frame.





 Plan of Correction - To be completed: 07/13/2019

K 0324
1. The semi-annual kitchen exhaust hood inspection that was revealed that cleanings were performed on September 13, 2018 and April 3, 2019 that the facility could not produce documentation verifying hood cleanings had been performed on a semi-annual basis will be reviewed with the foodservice department who is responsible for scheduling these cleanings on a semi-annual basis.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BLDG. 7 - Component: 04 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler system components were operational and maintained free of buildup of debris, on one of two building levels within this component.

Findings include:

1. Observation on May 13, 2019, at 2:00 pm, revealed, in NE-Wing by room 405, a sprinkler with a buildup of debris and paint.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the debris and paint on the sprinkler.


2. Observation made on May 13, 2019, at 2:20 pm, revealed that sprinkler riser gauges serving 1 north west wing and south west attic area were dated 2013.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed sprinkler gauges were not maintained.



 Plan of Correction - To be completed: 06/30/2019

K 0353
1. The sprinkler with a build-up of debris and paint revealed in the NE wing by room 405 will be replaced so that there isn't any impediment of the sprinkler's capability to perform in the recommended capacity of force and flow. A Facilities Management designee will perform a monthly preventative maintenance check for one quarter to ensure a duplication of this problem does not reoccur. The results will be sent to the Performance Improvement Department for review.

2. The sprinkler riser gauges serving 1 north west wing and south west attic revealed dated 2013 will be replaced with new gauges keeping us in compliance with the five-year replacement code.



NFPA 101 STANDARD Corridor - Doors: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.
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: BLDG. 7 - Component: 04 - Tag: 0363

Based on observation and interview it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch when tested, on one of two floors within this component.

Findings include:

1. Observation on May 13, 2019, between 1:25 pm, and 1:30 pm, revealed the following corridor doors failed to close and latch when tested:

a. 1:25 pm, SE-Wing, Resident room 207, door rubbing against frame;
b. 1:30 pm, SE-Wing, Resident room 205, blocked by cart and hangar on door knob.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the corridor doors failed to close and latch when tested.






 Plan of Correction - To be completed: 06/20/2019

K 0363
a. The SE wing resident room 207 that revealed door rubbing against frame will be repaired so that the door latches properly within its frame. This door will be monitored monthly for one quarter by a maintenance department designee and the results will be given to the Performance Improvement Department for review.
7/10/19
b. The SE wing resident room 205 that was revealed blocked by a cart and hanger on the door knob will be removed and this resident room will be monitored monthly by a maintenance department designee to ensure that there are not any obstructions blocking access to the room or objects left on the door preventing it from closing and latching monthly for one quarter. Additionally, all staff working within that unit will be given inservice training to ensure a duplication of this problem does not reoccur.



NFPA 101 STANDARD Electrical Systems - Other: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.
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: BLDG. 7 - Component: 04 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, on one of two levels.

Findings include:

1. Observation on May 13, 2019, at 2:20 pm, revealed, in NW basement near the entrance, the electrical panel was missing 2- circuit breaker protective blanks.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the missing protective blanks.




 Plan of Correction - To be completed: 06/30/2019

K 0911
1. The circuit breaker panel in NW basement that revealed (2) circuit breaker protective blanks missing will have protective blanks installed in those voids. To prevent a reoccurrence of this condition a quarterly audit conducted by our master trade electricians will be performed so that they are keeping in compliance of the electrical code. The results of this audit will be collected and stored in the maintenance department office so that this condition is consistently monitored on an ongoing basis.



NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: BLDG. 7 - Component: 04 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor electrical devices for unauthorized use, affecting one of six smoke compartments within this component.

Findings include:

1. Observation made on May 13, 2019 at 1:30 pm, revealed inside room 104, there was an oxygen concentrator plugged into a surge protector.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the unauthorized use of electrical device.




 Plan of Correction - To be completed: 06/08/2019

K 0920
1. The oxygen concentrator that was revealed plugged into a surge protector in resident room 104 will be removed and plugged directly into the wall outlet. A Maintenance Department designee will monitor this room monthly for one quarter so that a reoccurrence of this condition does not occur. Additionally, all staff working on this unit will be inserviced on the proper application of plugging in all medical equipment directly into the wall. Results of the audit will be given to Performance Improvement for review.



NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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.
Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: BLDG. 7 - Component: 04 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems, affecting one of two floors within this facility.
Findings include:
1. Review of documentation on May 14, 2019, between 8:30 a.m. and 10:30 a.m., revealed the required annual inspection of receptacles in patient care areas was not performed.

Receptacle testing should include the following:
a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the test was not performed.






 Plan of Correction - To be completed: 07/12/2019

K 0921
1. The required annual inspection of receptacles in patient care areas revealed that this process had not been completed to include:

a. Resident care rooms
b. Visual inspection of physical integrity
c. Correct polarity of the hot and neutral connections
d. Retention force of the grounding blade shall not be less that 4 oz. (except locking-type receptacles
This annual inspection will be performed for this inspection as well as will continue to be an annual inspection process for the Facilities Management Department and Fair Acres.


NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: BLDG. 7 - Component: 04 - Tag: 0923

Based on observation and interview, it was determined the facility failed to provide means of securing oxygen cylinders, on one of two floors within this component.

Findings include:

1. Observation on May 13, 2019, at 1:55 pm, revealed, in 1st floor NE Ice Room, there was a freestanding " E " size oxygen cylinder that was not secured.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the oxygen cylinder was not secured.







 Plan of Correction - To be completed: 06/17/2019

K 0923
a. The "E" size oxygen cylinder revealed in the NE ice room that was not secured will be secured by nursing personnel. A maintenance department/designee will inspect/audit monthly for one quarter and the Nursing stall will be inserviced on the proper storage and how to properly secure oxygen tanks. Results of the audit will be given to the Performance Improvement Department for review.



Initial comments:Name: BLDG. 8 - Component: 05 - Tag: 0000


Facility ID # 061002
Component 05
Building 8

Based on a Medicare/Medicaid Recertification Survey conducted on May 13-14, 2019, it was determined that Fair Acres Geriatric Center Building 8 was not in compliance with the following requirements of the Life Safety Code for an 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 fifteen-story building, with a basement, Type II (000), unprotected noncombustible construction, which is fully sprinklered.









 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit stair tower enclosures, affecting 3 of 15 levels within the component.

Findings include:

1. Observation made on May 13, 2019, between 8:30 am and 2:30 pm, eleventh floor corridor revealed an opening in the drywall partition in stair tower #1 wall, above the ceiling.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the opening in the drywall partition.


2. Observation made on May 13, 2019, at 9:45 am, ground floor, revealed the rated door to stair tower # 2 failed to positively latch.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the door failed to latch.


3. Observation made on May 13, 2019, at 10:40 am, first floor corridor, revealed an unsealed penetration in the stair tower #2 wall, above the ceiling.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the unsealed penetration.


4. Observation made on May 13, 2019, at 10:55 am, first floor corridor, revealed an unsealed penetration in the stair tower #1 wall, above the ceiling.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the unsealed penetration.










 Plan of Correction - To be completed: 06/30/2019

K 0225
1. The opening revealed in the drywall partition in stair tower #1 on the 11th floor above the ceiling will be closed using Hilti System No. W-J-1248. This stair tower #1 condition above the ceiling will be monitored monthly for one quarter and results given to Performance Improvement Department for review.
6/30/19
2. The floor rated door to stair tower #2 revealed to failed to positively latch into the frame will be repaired to ensure that the door properly latches within its frame. This door will be inspected/audited monthly for one quarter by a maintenance department designee to ensure the door properly latches within its frame as part of our preventative maintenance program. Results of the audit will be given to Performance Improvement Department for review.
7/13/19
3. On the 1st floor corridor, above the ceiling in the stair tower #2 that revealed an unsealed penetration will be closed using Hilti System No. W-J-1248. This stair tower #1 condition above the ceiling will be monitored monthly for one quarter and results given to Performance Improvement Department for review.
6/30/19
4. On the 1st floor corridor, above the ceiling in the stair tower #1 wall that revealed an unsealed penetration will be closed using Hilti System No. W-J-1248. This stair tower #1 condition above the ceiling will be monitored monthly for one quarter and results given to Performance Improvement Department for review.
6/30/19


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: BLDG. 8 - Component: 05 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain smoke tight seaparation of hazardous areas, in sprinklered locations, affecting two of fifteen smoke compartments.

Findings include:

1. Observation made on May 13, 2019, between 8:30 am and 2:30 pm, revealed hazardous area doors did not latch when tested, in the following locations:

a. 13th floor upper mechanical/storage room;
b. 10th floor soiled utility room.

Exit Interview with Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the doors failed to positively latch, in the above-named locations.













 Plan of Correction - To be completed: 07/13/2019

K 0321
a. The 13th floor upper mechanical/storage room door that failed to latch will be repaired to ensure that the door properly latches within its frame. This door will be inspected/audited monthly for one quarter by a maintenance department designee to ensure the door properly latches within its frame as part of our preventative maintenance program. Results of the audit will be given to Performance Improvement Department for review.given to Performance Improvement

b. The 10th floor soiled utility room door that failed to latch will be repaired to ensure that the door properly latches within its frame. This door will be inspected/audited monthly for one quarter by a maintenance department designee to ensure the door properly latches within its frame as part of our preventative maintenance program. Results of the audit will be Department for review.
7/13/19

NFPA 101 STANDARD Cooking Facilities: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.
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: BLDG. 8 - Component: 05 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure required training for kitchen personnel on fire protection systems, which could affect the entire components. Refer NFPA 101 2012 Edition, Section 19.3.2.5.3(5b).

Findings include:

1. Observation made on May 13, 2019, at 9:00 am, ground floor, revealed inside the main kitchen, kitchen personnel was unaware where the two kitchen fire supersession system manual pull stations were located when asked.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed personnel required training on protection of kitchen equipment.





 Plan of Correction - To be completed: 07/13/2019

K 0324
1. On the ground floor inside the main kitchen it was revealed that kitchen personnel were unaware where the two kitchen fire suppression system manual pull stations were located when asked. All kitchen personnel will be inserviced on where the two manual pull stations for the kitchen fire suppression systems are located so they are aware when asked. Random kitchen employees at different times of the day will be questioned by Maintenance staff monthly for one quarter. Results of this inspection will be sent to Performance Improvement for review.


NFPA 101 STANDARD Smoke Detection: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.
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: BLDG. 8 - Component: 05 - Tag: 0347

Based upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting the entire component.

Findings include:

1. Observations made on May 13, 2019, between 9:30 am and 9:50 am revealed missing suspended ceiling tiles which could delay activation of smoke detectors, in the following locations:

a. 9:30 am, ground floor, closet inside the PT room.
b. 9:35 am, ground floor inside PT room, inside PT office number 1.
c. 9:50 am, ground floor rehab wheel chair storage room.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the missing ceiling tiles in the above named locations.


2. Review of documents on May 14, 2019, between 8:30 am and 10:30 am, revealed facility was unable to provide two year sensitivity testing documentation for Building 8.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the documentation was not available.











 Plan of Correction - To be completed: 06/30/2019

K 0347
a. The missing suspended ceiling tiles which could delay activation of smoke detectors in the ground floor closet inside the PT room ceiling tiles will be installed so the activation of the smoke detectors will not be delayed in the event of a smoke situation.
b. The missing suspended ceiling tiles which could delay activation of smoke detectors in the ground floor inside the PT room inside PT office #1 ceiling tiles will be installed so the activation of the smoke detectors will not be delayed in the event of a smoke situation.
c. The missing suspended ceiling tiles which could delay activation of smoke detectors in the ground floor Rehab wheel chair storage room, ceiling tiles will be installed so the activation of the smoke detectors will not be delayed in the event of a smoke situation.
There will be a monthly audit conducted for one quarter to prevent a reoccurrence of this condition. Results will be sent to Performance Improvement for review.
6/30/19
2. The documents that were reviewed on May 14th between 8:30am and 10:30am that revealed the facility was unable to provide two year sensitivity testing documentation for building 8 will be rectified by having our contractor providing a sensitivity testing conducted immediately.


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: BLDG. 8 - Component: 05 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire component.

Findings include:

1. Observation made on May 13, 2019 at 8:50 am, ground floor, revealed inside the sprinkler riser room, there were two sprinkler riser gauges located near the ceiling that were dated 2008.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the gauges were dated 2008.





 Plan of Correction - To be completed: 06/30/2019

K 0353
1. The two sprinkler gauges revealed inside the ground floor sprinkler riser room located near the ceiling and were dated 2008, will be replaced with (2) new 5- year gauges so we will be in compliance.

6/30/19

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were maintained, affecting 1 of 15 smoke zones within the component.

Findings include:

1. Observation made on May 13, 2019 at 8:40 am, ground floor, revealed a fire extinguisher inside the fire pump room was missing a seal on the pull-pin.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the seal was missing.








 Plan of Correction - To be completed: 06/08/2019

K 0355
1. On the ground floor in the fire pump room where there was a fire extinguisher that was missing a seal on the pull-pin will be replaced so that we are in compliance with NFPA regulations. A monthly audit will be conducted by a maintenance department designee for one quarter. Results of the audit will be sent to the Performance Improvement Department for review.


NFPA 101 STANDARD Corridor - Doors: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.
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: BLDG. 8 - Component: 05 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting 2 of 15 smoke zones within the component.

Findings include:

1. Observation on May 13, 2019, between 8:30 am and 2:30 pm, revealed the door to resident room 1005 was missing a door knob and did not positively self-latch into its frame, 10th floor.

Exit Interview with Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the door failed to positively latch.

2. Observation on May 13, 2019, at 11:43 am, third floor, revealed the door to the nurses lounge had an approximately one inch diameter hole in it above the door knob.

Exit Interview with Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the door had a hole in it.






 Plan of Correction - To be completed: 07/13/2019

K 0363
1. On the 10th floor resident room 1005 where it was revealed that the door was missing a door knob and did not positively self-latch into its frame will have a new door knob installed on the door and the door will be repaired so that the door will self-latch into its frame. A maintenance designee will monitor this door for one quarter and the results will be given to the Performance Improvement Department for review.
2. The door to the 3rd floor nurses lounge that revealed an approximately one inch diameter hole will be filled to close the void in the door.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain that smoke barrier walls were free of unsealed penetrations, affecting 4 of 15 smoke zones within the component.

Findings include:

1. Observations made on May 13, 2019, between 11:16 am and 11:32 am, revealed unsealed smoke barrier wall penetrations in the following locations:

a. 11:16 am, 2nd floor, around a blue data wire above the smoke barrier double doors near resident room #208, above the ceiling.
b. 11:32 am, 3rd floor, around a bundle of white cable wires, above the smoke barrier double doors near the women's tub room, above the ceiling.

Exit Interview with Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the unsealed penetrations in the above named locations.




 Plan of Correction - To be completed: 06/30/2019

K 0372

a. The unsealed smoke barrier wall penetration on the second floor around a blue data wire above the ceiling above the smoke barrier double doors near resident room 208 will be sealed with Hilti System No. W-J-3215 to maintain integrity of the wall assembly. The Facilities Management Department will ensure that any contracting work performed above the ceiling will not interfere with the integrity of the of the smoke barrier wall assembly by inspecting work performed before, during and after construction. A monthly inspection by a Maintenance Department designee will also be performed and recorded and results will be sent to the Performance Improvement Department for review.

b. The unsealed penetration around a bundle of white cable wires above the ceiling above the smoke barrier double doors on the 3rd floor near the women's tub room will be sealed with Hilti System No. W-J-3215 to maintain integrity of the wall assembly. The Facilities Management Department will ensure that any contracting work performed above the ceiling will not interfere with the integrity of the of the smoke barrier wall assembly by inspecting work performed before, during and after construction. A monthly inspection by a Maintenance Department designee will also be performed and recorded and results will be sent to the Performance Improvement Department for review.

6/30/19


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0374

Based on observation and interview it was determined that the facility failed to ensure that smoke barrier doors were maintained to fully close to resist the passage of smoke, affecting 6 of 15 smoke zones within the component.

Findings include:

1. Observations made on May 13, 2019, between 8:30 am, and 2:30 pm, revealed the following smoke barrier doors failed to close when tested:

a. Between 8:30 am and 2:30 pm, 8th floor, smoke barrier door next to room 808, had damage to hardware and missing screws.
b. Between 8:30 am and 2:30 pm, 7th floor, smoke barrier door next to room 720.
c. Between 8:30 am and 1:20 pm, 4th floor, smoke barrier door next to room 408.

Interview at the exit conference with the Administrator and Maintenance Director on May 13, 2019, at 2:30 pm, confirmed the smoke barrier doors failed to close, in the above named locations.








 Plan of Correction - To be completed: 07/12/2019

K 0374
a. The smoke barrier door on the eighth floor by resident room 808 that had damage to hardware and was missing screws and failed to close will be repaired/adjusted so that the door fully closes and positively latches within its frame. The smoke barrier door on the eighth floor by resident room 808 will be inspected monthly by Maintenance Department designee for one quarter. Results of the inspection will be given to performance improvement department for review. 7/12/19

b. The smoke barrier doors on the seventh floor by resident room 720 that failed to fully close and latch within its frame will be repaired/adjusted so that the door fully closes and positively latches within its frame. The smoke barrier door on the seventh floor by resident room 720 will be inspected monthly by Maintenance Department designee for one quarter. Results of the inspection will be given to performance improvement department for review.
7/12/19

c. The center smoke barrier doors on the fourth floor next to room 408 that failed to fully close will be repaired/adjusted so that the door fully closes and positively latches within its frame. The center smoke barrier doors on the fourth floor will be inspected monthly by Maintenance Department designee for one quarter. Results of the inspection will be given to performance improvement department for review.


NFPA 101 STANDARD HVAC - Any Heating Device: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.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0522

Based on observation and interview, it was determined the facility failed to maintain that heating units were free of combustible materials, affecting 1 of 15 smoke zones within the component.

Findings include:

1. Observation made on May 14, 2019 at 10:52 am, 1st floor, revealed bundles of clothing were placed on a heater unit inside resident room #114.

Exit Interview with Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed there was clothing on a heater unit.



 Plan of Correction - To be completed: 06/08/2019

K 0522
1. The bundles of clothing revealed on the heater unit inside resident room 114 will be removed to her clothing storage dressers inside their room. Will work collaboration with Social Services to eliminate clutter and along with Nursing to ensure this resident understands that storing anything on their heating units is not permitted. A weekly audit will be conducted by a maintenance department designee as well as a nursing assistant for one quarter to insure there is not a reoccurrence of this condition. Results of the audit will be sent to the Performance Improvement Department for review.


NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of chutes, affecting 1 of 15 levels within the component.

Findings include:

1. Observation made on May 13, 2019 at 10:52 am, first floor, revealed inside the trash chute room, the access door to the trash chute failed to positively latch.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the door to the chute failed to latch.





 Plan of Correction - To be completed: 07/12/2019

K 0541
a. The 1st floor trash chute door that failed to close and positively latch when tested will be repaired/adjusted so that the door latches positively within its frame. The Facilities Management Department will include an inspection of trash chute doors on our bi-weekly preventative maintenance rounds report so that any discrepancies related to the chute doors can be found and corrected.



NFPA 101 STANDARD Electrical Systems - Other: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.
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: BLDG. 8 - Component: 05 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring, affecting 2 of 15 smoke zones within the component. Installation shall be in accordance with NFPA 99 Section 6.3.2.1.

Findings include:

1. Observation made on May 13, 2019, at 9:15 am, ground floor corridor, revealed an unsecured junction box above the door to stair tower number 1, above the suspended ceiling.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the unsecured junction box.


2. Observation made on May 13, 2019, at 11:30 am, third floor, revealed an open junction box with exposed electrical wiring above the smoke barrier double doors near the women's tub room, above the suspended ceiling.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the open junction box.







 Plan of Correction - To be completed: 06/30/2019

K 0911
1. In the ground floor corridor above the suspended ceiling above stair tower #1 door where it was revealed an unsecured junction box was found will be secured above the suspended ceiling. This condition will be monitored monthly for one quarter to ensure that the junction box stays secured. The results of this monitoring will be sent to the Performance Improvement Department for review.
6/30/19
2. On the 3rd floor above the suspended ceiling above the smoke barrier double doors near the women's tub room where it was revealed an open junction box with exposed electrical wiring will be closed to conceal all electrical wiring. This condition will be monitored monthly for one quarter. The results of this monitoring will be sent to the Performance Improvement Department for review.



NFPA 101 STANDARD Electrical Systems - Receptacles: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 - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0912

Based on observation and interview, it was determined the facility failed to ensure electrical devices in the vicinity of a water source were connected to a GFI type circuit, affecting 1 of 15 smoke zones within the component.

Findings include:

1. Observation made on May 13, 2019 at 9:40 am, ground floor, revealed inside the PT room, three hydrocollators were plugged into non-GFI type recepticals.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the hydrocollators were plugged into non-GFI type recepticals.





 Plan of Correction - To be completed: 07/12/2019

K 0912
a. The hydrocollator revealed that was not plugged into a ground fault circuit interrupter (GFCI) receptacle inside the Physical Therapy Department will have (3) GFCI installed so that the hydrocollator's will be properly protected in accordance of the current electrical code. These hydrocollator's will be monitored monthly for one quarter by a Maintenance department designee to ensure it is consistently plugged into the GFCI receptacles. All staff within the Physical Therapy Department will be inserviced as well to maintain compliance.



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: BLDG. 8 - Component: 05 - Tag: 0920

Based on observation and interview, it was determined the facility failed to ensure that the use of extension cords is prohibited, affecting 1 of 15 smoke zones within the component.

Findings include:

1. Observation made on May 14, 2019, at 10:20 am, Main Floor, revealed a coffee maker was plugged into an extension cord inside the nurse supervisors office.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the prohibited use of an extension cord.




 Plan of Correction - To be completed: 06/08/2019

K 0920
a. On the Main Floor inside the nurse supervisor's office where it was revealed a coffee maker was plugged into an unauthorized extension cord will be removed. Maintenance Department designee will monitor the nurse supervisor's office as well as inform Nursing Personnel that extension cords are a violation of the Life Safety Code. Results of the audit will be given to Performance Improvement for review. The nursing department staff will be inserviced and will contact the family to ensure that they are aware of this deficient practice.


NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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 - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems affecting twelve of fifteen floors within this facility.
Findings include:
1. Review of documentation on May 14, 2019, between 8:30 a.m. and 10:30 a.m., revealed the required annual inspection of receptacles in patient care areas was not performed.

Receptacle testing should include the following:
a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:30 pm, confirmed the test was not performed.





 Plan of Correction - To be completed: 07/12/2019

K 0921
1. The required annual inspection of receptacles in patient care areas revealed that this process had not been completed to include:

a. Resident care rooms
b. Visual inspection of physical integrity
c. Correct polarity of the hot and neutral connections
d. Retention force of the grounding blade shall not be less that 4 oz. (except locking-type receptacles
This annual inspection will be performed for this inspection as well as will continue to be an annual inspection process for the Facilities Management Department and Fair Acres. This process will commence immediately.



NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure that outdoor portable oxygen cylinder storage locations were secured to prevent unauthorized access, affecting 1 of 15 levels within the component.

Findings include:

1. Observation made on May 13, 2019 at 8:45 am, ground floor, revealed the large outdoor portable oxygen cylinder storage cage was not secured to prevent unauthorized access.

Interview at the exit conference with the Administrator and Maintenance Director on May 14, 2019, at 2:45 pm, confirmed the storage cage was not secured.





 Plan of Correction - To be completed: 06/17/2019

K 0923
a. The oxygen storage cage that holds the facilities portable oxygen cylinders that was revealed was not secured to prevent unauthorized access will be pad locked 24/7. Maintenance department/designee will inspect/audit monthly for one quarter and the Utility Aides who access the storage cage for deliveries will also be inserviced on new facility policy of keeping this storage cage locked 24/7. Results of the audit will be given to the Performance Improvement Department for review.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port