Nursing Investigation Results -

Pennsylvania Department of Health
GWYNEDD HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GWYNEDD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

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GWYNEDD HEALTHCARE AND REHABILITATION 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 February 25, 2019, it was determined that Gwynedd Healthcare And Rehabilitation Center was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(a)(3) REQUIREMENT EP Program Patient Population: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.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(3) Address patient/client population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*Note: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC, FQHC, or ESRD facilities.]
Observations:
Name: - Component: -- - Tag: 0007

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) program addressing the patient population, affecting the entire facility.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed the Emergency Preparedness plan did not address patient/client population, persons at risk, and the type of services the facility has the ability to provide in an emergency.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the EP plan did not specify the population served within the facility, in the event of an emergency.





 Plan of Correction - To be completed: 04/02/2019

1. The facility will update our Emergency Preparedness Plan to ensure that we address our patient/client population, persons at risk, and the types of services we have the ability to provide in an emergency.
2. Audits will be completed monthlyx3 to ensure that the emergency preparedness plan addresses our patient/client population, persons at risk, and the types of services we have the ability to provide in an emergency.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

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

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015
Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan that included policies and procedures that include subsistence needs for staff and residents during an emergency, affecting the entire facility.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed the Emergency Preparedness plan did not include policies and procedures for provisions for subsistence needs for staff and residents, for the following:

a. Staff;
b. Medical and pharmaceutical supplies;
c. Sewage and waste disposal.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the EP plan did not include all required provisions to be used in the event of an emergency.












 Plan of Correction - To be completed: 04/02/2019

1. The facility will update our Emergency Preparedness Plan to ensure that we include policies and procedures for provisions for subsistence needs for staff and residents which include medical and pharmaceutical supplies and sewage and waste disposal.
2. Audits will be completed monthlyx3 to ensure that procedures for provisions for subsistence needs for staff and residents include medical and pharmaceutical supplies and sewage and waste disposal are included in the facility Emergency Preparedness Plan.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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 [facility] 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:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034
Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) Communication plan for sharing information on occupancy needs, affecting the entire facility.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed the Emergency Preparedness plan did not provide a Communication plan that includes a means of providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction (local and state public health departments, the Incident Command Center, The Emergency Operations Center, or designee), to be reviewed and updated at least annually.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the EP plan did not include a communication plan for a means of providing information about their occupancy, in the event of an emergency.





 Plan of Correction - To be completed: 04/02/2019

1. The facility will update our Emergency Preparedness Plan to ensure that our communication plan includes a means of providing information about our occupancy in the event of an emergency.
2. Audits will be completed monthlyx3 to ensure that our communication plan includes a means for providing information about our occupancy in the event of an emergency.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

483.73(d)(1) REQUIREMENT EP Training Program: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.
(1) Training program. The [facility, except CAHs, ASCs, PACE organizations, PRTFs, Hospices, and dialysis facilities] must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For Hospitals at 482.15(d) and RHCs/FQHCs at 491.12:] (1) Training program. The [Hospital or RHC/FQHC] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For Hospices at 418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least annually.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.

*[For PRTFs at 441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.

*[For PACE at 460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.

*[For CORFs at 485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.

*[For CAHs at 485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CMHCs at 485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least annually.

Observations:
Name: - Component: -- - Tag: 0037
Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) Training program based on the emergency plan, risk assessment, policies and procedures, and communication plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m, revealed the Emergency Preparedness plan did not include a written training program that includes initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the EP plan did not include a written initial training program.










 Plan of Correction - To be completed: 04/02/2019

1. The facility will update our Emergency Preparedness Plan to include a written training program that includes initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers consistent with their expected roles.
2. Audits will be completed monthlyx3 to ensure that the written training program is included in the facilities Emergency Preparedness Plan.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

Initial comments:Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0000


Facility ID# 075002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 25, 2019, it was determined that Gwynedd Healthcare and Rehabilitation Center 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 483.70(a).

This is a one story building, with a partial basement, Type II (000), unprotected non-combustible construction, which 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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0211

Based on observation, document review and interview, it was determined the facility failed to maintain acceptable exit access, affecting 2 of seven exits from the facility.

Findings include:

1. Observation made on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed headroom inside the basement-level stairwell enclosure, from the stair tread to the overhead obstruction, was less than the required minimum six feet eight inch clearance. The stairwell provides one of two recognized means of egress from the basement.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed testing of emergency generator system components were not completed.


2. Observation made on February 25, 2019, at 215 p.m., revealed snow partially impeded the exterior exit discharge to a public way from the main dining room, adjacent to parked cars.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the means of egress was partially obstructed.






 Plan of Correction - To be completed: 04/02/2019

1. We would like to have the FSES updated for the headroom inside the basement-level stairwell enclosure. The egress exit that was partially obstructed was immediately corrected. The facility will correct by elimination of a parking space located in the area to ensure enough room for egress in the event of any emergency. The facility will ensure that snow removal will not be obstructing egress.
2. Audits will be completed weeklyx4 then monthlyx3 to ensure that areas of egress are not obstructed.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.


NFPA 101 STANDARD Fire Alarm System - Installation: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.
Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8




Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0341
Based on observation and interview, it was determined the facility failed to maintain fire alarm components in operable condition, affecting 2 of three smoke compartments within the facility.

Findings Include:

1. Observation made on February 25, 2018, between 2:35 p.m. and 3:00 p.m., revealed corridor smoke detectors in close proximity to suspended ceiling diffusers (approximately 6 to 18" inches), which could effect the proper operation of the detectors, at the following locations:

a. outside the personal laundry room outside activities;
b. outside room C17;
c. outside room B33;
d. outside the B wing nurse station, near the loading dock.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed fire alarm system components were partially obstructed.




 Plan of Correction - To be completed: 04/02/2019

1. The smoke detectors in close proximity to suspended ceiling diffusers noted outside personal laundry room outside activities, outside room C17, outside room B33, and outside the B wing nursing station near the loading dock were moved.
2. Audits will be completed weeklyx4 then monthlyx3 to ensure that the fire alarm system components are not partially obstructed.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

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

Based on observation, document review and interview, it was determined the facility failed to maintain required inspections of the automatic sprinkler system, affecting the entire facility.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed a quarterly sprinkler inspection report was unavailable between February 1, 2018 and July 9, 2018.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed quarterly sprinkler inspections were not completed for 2018.


2. Observation made on February 25, 2019, at 1:30 p.m., revealed the sprinkler head protruded from the suspended ceiling in the corridor outside the medical records office.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the sprinkler was not smoke tight within the ceiling assembly.









 Plan of Correction - To be completed: 04/02/2019

1. The facility will ensure that the quarterly inspection reports are available and completed timely. The facility will fix the sprinkler head and secure it to the suspended ceiling in the corridor outside of the medical records office to ensure that it's not protruding from the ceiling tile.
2. Audits will be completed weeklyx4 then monthlyx3 to ensure compliance.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0355

Based on observation, document review and interview, it was determined the facility failed to maintain required certifications and ensure proper operation of fire extinguishers, affecting the entire building.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed the facility was unable to provide certifications for persons performing maintenance and recharging of fire extinguishers.

Exit Interview with the Facility Administrator and the Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed fire extinguisher inspection certifications were not available at the time of survey.


2. Observation made on February 25, 2019, at 2:08 p.m., revealed the Type K fire extinguisher located near the rear exit door inside the kitchen, pressure gauge was in the yellow condition, indicating the extinguisher was overcharged. Overfilling could render the fire extinguisher dangerous or ineffective.

Exit Interview with the Facility Administrator and the Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the fire extinguisher was overcharged.






 Plan of Correction - To be completed: 04/02/2019

1. The facility will ensure that certifications for persons performing maintenance and recharging of fire extinguishers are available. The facility will have the outside contractor replace the overcharged type k fire extinguisher noted near the rear exit door inside the kitchen.
2. Random audits will be completed weeklyx4 then monthlyx3 to ensure that the facility has the appropriate certifications for the person performing maintenance and recharging of fire extinguishers are available and that the fire extinguishers are not overcharged.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain positive latching of corridor doors along the means of egress, affecting 1 of three smoke compartments.

Findings Include:

1. Observation made on February 25, 2019, at 2:08 p.m., revealed the double doors along the dining room corridor would not positively self-latch into their frame when tested.

Exit Interview with the Facility Administrator and the Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed the corridor doors required adjustment.





 Plan of Correction - To be completed: 04/02/2019

1. The double doors along the dining room corridor was fixed and now positively self-latches into their frame when tested.
2. Audits will be completed weeklyx4 then monthlyx3 to ensure that corridor doors along the means of egress positively latch when tested.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

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

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0741
Based on observation and interview, it was determined the facility failed to maintain designated smoking areas per regulations, affecting 1 of two smoking locations.

Findings Include:

1. Observation made on February 25, 2019, at 2:50 p.m., revealed the back smoking area had an open ashtray, lacking a self-closing cover device.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed proper smoking containers were not available.




 Plan of Correction - To be completed: 04/02/2019

1. The open ashtray in the back- employee smoking area was immediately removed and a self-closing covered device was installed.
2. Audits will be completed weeklyx3 then monthly x4 to ensure that the designated smoking areas are maintained per regulations and that self-closing covered devices are utilized instead of open ashtrays.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.


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 Receptacles
Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0917
Based on document review and interview, it was determined the facility failed to maintain required testing of electrical receptacles, affecting the entire facility.

Findings include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed electrical receptacles at resident bed locations were not tested, in areas of sedation or where anesthesia is used, for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. 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).

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed testing of electrical receptacles was not completed.




 Plan of Correction - To be completed: 04/02/2019

1. The facility will test the electrical receptables throughout the facility. The following will be included in the receptacle testing: resident care rooms, visual inspection of physical integrity, correct polarity of the hot and neutral connections and the retention force of the grounding blade shall be not less than 115g.
2. The facility will complete random audits monthlyx3 to ensure that the electrical receptables are tested.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.

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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required inspections of Essential Electrical System alternate power source, affecting the entire facility.

Findings Include:

1. Documentation reviewed on February 25, 2019, between 9:30 a.m. and 3:00 p.m., revealed weekly visual inspections of electrolyte levels for the emergency generator's battery were not conducted.

Exit Interview with the Facility Administrator and Director of Maintenance on February 25, 2019, at 3:00 p.m., confirmed testing of emergency generator system components were not completed.








 Plan of Correction - To be completed: 04/02/2019

1. The facility is conducting weekly visual inspections of the electrolyte levels of the emergency generator's battery. This is now a part of our emergency generator inspections.
2. Audits will be completed weeklyx4 then monthlyx3 to ensure that the visual inspections of the electrolyte levels of the emergency generators battery are being conducted.
3. Results of the audits will be reported at the facility QAPI meeting. The QAPI committee will review and discuss the need for further audits.


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