Nursing Investigation Results -

Pennsylvania Department of Health
GERMANTOWN HOME
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GERMANTOWN HOME
Inspection Results For:

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

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GERMANTOWN HOME - 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 January 15, 2019, it was determined that Germantown Home was not in compliance with the requirements of 42 CFR 483.73.


 Plan of Correction:


483.73(a)(1)-(2) REQUIREMENT Plan Based on All Hazards Risk Assessment: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:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

*[For LTC facilities at 483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

*[For ICF/IIDs at 483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness plan/program, that was based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, affecting the entire facility.
Findings include
1. Document review on January 15, 2019, at 8:00 am, revealed the facility failed to establish and maintain a comprehensive emergency preparedness program that was based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 03/16/2019

The facility will develop an emergency preparedness plan/program that will be based on and will include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, affecting the entire facility.
Administrator and Maintenance Director or designee will review and update the Emergency Preparedness Plan annually to ensure compliance.

483.73(b)(8) REQUIREMENT Roles Under a Waiver Declared by Secretary:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at 403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to develop Policies and Procedures to include the facility's role in providing alternate care at alternate care sites during emergencies, as part of their Emergency Preparedness plan, affecting the entire facility.

Findings Include:

1. Document review on January 15, 2019, at 8:00 am, revealed the Emergency Preparedness plan did not include Policies and Procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver during a declared emergency.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 03/16/2019

The facility will develop Policies and Procedures to include the facility's role in providing alternate care at alternate care sites during emergencies, as part of its Emergency Preparedness plan.
The facility will review Emergency Preparedness Plan at least annually to ensure compliance.
Administrator and Maintenance Director or designee will review and update the Emergency Preparedness Plan annually to ensure compliance.

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 January 15, 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 the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 03/16/2019

The facility will develop an Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.
Administrator and Maintenance Director or designee will review and update the Emergency Preparedness Plan annually to ensure compliance.

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 January 15, 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 emergency preparedness plan.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 03/16/2019

The facility will conduct the required annual exercises to test the facility's emergency preparedness plan.
Administrator and Maintenance Director or designee will review and update the Emergency Preparedness Plan annually to ensure compliance.

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

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

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

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

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

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

Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness Plan to include a plan to ensure the facility's emergency generator provides continuous power during an emergency, affecting the entire facility.

Findings include:

1. Document review on January 15, 2019, at 8:00 am, revealed the facility's Emergency Preparedness Plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event there primary fuel supplier is unavailable during an emergency.
Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 03/16/2019

The facility will complete a written plan which will include written agreements/contracts with a secondary fuel supplier for the facility's emergency generator. The written plan and the written agreements will be included in the facility's Emergency Preparedness Plan.
Both companies' contracts and contact information will be kept in the facility's Emergency Preparedness Manual. The facility's Emergency Preparedness Manual will be reviewed annually by the administrator and the maintenance director.

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


Facility ID# 122702
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on completed on January 15, 2019, it was determined that Germantown Home 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 four-story, Type II (222), fire resistive construction, which is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common walls, affecting 1 of 4 levels within the facility.

Findings include:

1. Observation made on January 15, 2019, at 12:35 pm, ground floor, revealed above the rated double doors near stair tower A that separates the skilled nursing unit from the non-healthcare building component, there was an unsealed penetration in the rated wall around data wires, above the suspended ceiling.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the unsealed penetration.





 Plan of Correction - To be completed: 03/16/2019

A through penetration fire stop system was used to seal the penetration through the rated partition.
The Maintenance director or designee will ensure that contractors do not leave any penetrations in rated walls after services.
Maintenance director or designee will inspect for penetrations monthly, and findings will be reported in QAPI x 3 months, and as needed thereafter.

NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and documentation it was determined that the facility failed to maintain the fire resistive rating of the facility's building construction type, affecting 2 of 4 levels within the facility.

Findings include:

1. Observation made on January 15, 2019 at 11:00 am, revealed inside the 3rd floor small dining room that is located across from the soiled utility room, there were eleven incomplete rated light bonnets.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed there were eleven incomplete light bonnets.

2. Observation made on January 15, 2019 at 12:20 pm, 2nd floor, revealed inside resident room # 230, above the television, above the ceiling, there was a structural beam missing sections of fireproofing.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the structural beam was missing sections of fireproofing.



 Plan of Correction - To be completed: 03/16/2019

All fire bonnets were replaced. Maintenance director or designee will inspect all contractors' work within this area to ensure that fire bonnets are intact.
Structural beam fireproofing will be installed using UL design NO. UL263. The Maintenance director or designee will ensure that contractors do not damage fireproofing during work in this area.
Maintenance director or designee will inspect fire bonnets and structural beams monthly to insure proper fit and structural integrity of fireproofing, and findings will be reported in QAPI x 3 months, and as needed thereafter.

NFPA 101 STANDARD Egress 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.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to ensure egress doors with magnetic latching devices functioned properly, affecting 1 of 3 rated stair tower enclosures within the facility.
Findings include:
1. Observation made on January 15, 2019, at 10:18 am, 4th floor, revealed near resident room # 430, the electro-magnetic latching device installed on the egress door to the B stair tower was not functioning when tested.
Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the electro-magnetic latch was not functioning.







 Plan of Correction - To be completed: 03/16/2019

4th floor stair tower door (near resident room #430 B) was adjusted to latch into frame. The electromagnetic latching device installed on the egress door to the B stair tower is now functioning appropriately.
Maintenance director or designee will inspect stair tower doors monthly for proper operation, and findings will be reported in QAPI x 3 months, and as needed thereafter.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0225


Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of stair tower enclosures, affecting 1 of 3 stair towers within the facility.

Findings include:

1. Observation made on January 15, 2019, at 12:11 pm, 2nd floor, revealed in the corridor, above the door to the center stair tower, above the ceiling, there were unsealed penetrations in the stair tower wall around three bar-joists.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the unsealed penetrations.






 Plan of Correction - To be completed: 03/16/2019

A through penetration fire stop system was used to seal the penetration through the rated partition. Maintenance director or designee will ensure that contractors do not leave any penetrations in rated walls after services.
Maintenance director or designee will inspect for penetrations monthly, and findings will be reported in QAPI x 3 months, and as needed thereafter.

NFPA 101 STANDARD Fire Alarm - Control Functions: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 - Control Functions
The fire alarm automatically activates required control functions and is provided with an alternative power supply in accordance with NFPA 72.
18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0344

Based on observation and interview, it was determined the facility failed to ensure the fire alarm automatically activates required control functions, affecting 2 of 10 smoke zones within the facility.

Findings include:

Observation made on January 15, 2019, at 1:20 pm, 2nd floor, revealed one leaf of the magnetic hold-open smoke barrier double doors located near resident room # 221, failed to release and close upon activation of the fire alarm.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the door failed to release upon activation of the fire alarm.




 Plan of Correction - To be completed: 03/16/2019

The door sweep on smoke barrier door located near resident room #221 was replaced to allow the door to close upon release of the magnetic hold-open device. The door is now able to release and close upon activation of the fire alarm.
Maintenance director or designee will inspect smoke barrier doors monthly during fire drills to ensure proper function and findings will be reported in QAPI x 3 months, and as needed thereafter.

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors in a smoke resistive ceiling assembly which could delay activation of the fire alarm, affecting 2 of 10 smoke zones within the facility.

Findings include:
1. Observations made on January 15, 2019, between 12:05 pm and 12:58 pm , revealed unsealed penetrations in suspended ceiling tiles near smoke detectors in the following locations:

a. 12:05 pm, 2nd floor, inside the med room;
b. 12:58 pm, ground floor, inside the hot water heater room.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the unsealed penetrations near smoke detectors, in the above named locations.





 Plan of Correction - To be completed: 03/16/2019

The ceiling tile was replaced with rated ceiling tiles (Armstrong 755B) to maintain the fire resistant integrity of the rated suspended ceiling system. Maintenance director or designee will inspect smoke heads monthly and will accompany the fire prevention company quarterly, for joint inspections, to ensure no penetrations exist. Findings will be reported in QAPI x 3 months, and as needed thereafter.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview it was determined the facility failed to maintain automatic sprinkler system components, affecting 3 of 4 levels within the facility.

Findings include:

Observations made on January 15, 2019, between 11:15 am and 12:55 pm, revealed missing sprinkler escutcheons in the following locations:

a. 11:15 am, 3rd floor, in the corridor across from the personal care supply room;
b. 12:09 pm, 2nd floor, inside the main dining room, eight missing sprinkler escutcheons;
c. 12:55 pm, ground floor, inside the scheduling office.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the missing sprinkler escutcheons in the above named locations.





 Plan of Correction - To be completed: 03/16/2019

The missing sprinkler escutcheons (3rd floor in the corridor across from the personal care supply room, 2nd floor inside main dining room, and ground floor inside the scheduling office) have been replaced.
Maintenance director or designee will inspect sprinkler escutcheons quarterly with sprinkler contractor.
Maintenance director or designee will reported in QAPI quarterly x 2 quarters, and as needed thereafter.

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

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

Based on observation and interview, it was determined the facility failed to ensure doors positively latch into the door frame, affecting 1 of 10 smoke zones within the facility.

Findings include:

1. Observation made on January 15, 2019, at 11:10 am, 3rd floor, revealed the corridor door to resident room # 307 failed to positively latch.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the door failed to latch.







 Plan of Correction - To be completed: 03/16/2019

The door on room #307 was adjusted to positively latch into the frame. Maintenance director or designee will inspect all resident room doors semiannually to ensure positive latching.
Maintenance director or designee will report in QAPI quarterly semi annually x 2 semiannual reporting periods, and as needed thereafter.

NFPA 101 STANDARD HVAC - Any Heating Device:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC - 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: MAIN BUILDING 01 - Component: 01 - Tag: 0522
Based on observation and interview, it was determined that the facility failed to ensure heating devices are installed so combustible materials cannot be ignited by the device, affecting 3 of 4 levels within the facility.

Findings include:

1. Observations made on January 15, 2019, between 10:25 am and 1:15 pm revealed combustible materials stored in close proximity to heaters in the following locations:

a. 10:25 am, 4th floor, inside resident room # 428, holiday decorations were placed on top of a heater unit;
b. 10:35 am, 4th floor, inside the staff lounge, clothing was placed on top of a heater unit;
c. 10:45 am, 4th floor, inside resident room # 404, paper was placed on top of a heater unit;
d. 11:05 am, 3rd floor, inside resident room # 313, paper was placed on top of a heater unit;
e. 11:20 am, 3rd floor, inside the staff lounge, clothing was placed on top of a heater unit;
f. 1:15 pm, ground floor, inside the Assistant Director of Nursing Office, paper was placed on top of, and against the face of a heater unit.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the combustible materials stored in close proximity to heaters in the above named locations.



 Plan of Correction - To be completed: 03/16/2019


The facility has a central heating plant which 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. The central heating plant is not located in the building.
Resident room # 428, holiday decorations were removed.
4th floor, inside the staff lounge, clothing was removed from the heater unit.
4th floor, inside resident room # 404, paper was removed from top of a heater unit.
3rd floor, inside resident room # 313, paper was removed from top of a heater unit.
3rd floor, inside the staff lounge, clothing was removed from the top of a heater unit.
Ground floor, inside the Assistant Director of Nursing Office, paper was removed from top and against the face of a heater unit.
Nursing home staff will be educated to check to ensure items are not stored on radiator units.
Maintenance director or designee will inspect for items on heating devices monthly and findings will be reported in QAPI x 3 months, and as needed thereafter.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914
Based on documentation review and interview it was determined the facility failed to ensure that electrical receptacles were tested at resident bed locations, affecting 180 of 180 resident bed locations within the facility.

Findings include:

1. Document review on January 15, 2019, at 8:00 am, revealed electrical receptacles at resident bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested 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).

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the testing documentation could not be provided.



 Plan of Correction - To be completed: 03/16/2019

The facility will ensure that electrical receptacles are tested at all resident bed locations. The facility will ensure testing for non-hospital grade receptacles at intervals not exceeding 12 months, and for hospital grade receptacles minimally not exceeding 12 months
Receptacle testing will include the following:
All resident room receptacles at patient beds will be visually inspected for physical integrity, correct polarity and retention force. Maintenance director or designee will inspect annually for compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to ensure the emergency generator was visually inspected weekly, for 11 out of the 52 previous weeks, affecting the entire facility.
Findings include:
1. Document review on January 15, 2019, at 8:00 am, revealed the facility could not provide documentation showing that weekly generator visual inspections were performed between June 26, 2018 and September 19, 2018.
Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the documentation could not be provided.







 Plan of Correction - To be completed: 03/16/2019

The facility will continue to visually inspect the generator and document such inspections weekly.
Maintenance director or designee will ensure that proper documentation is maintained, and report findings in QAPI x 3 months, and as needed thereafter.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure portable oxygen cylinders stored outdoors were in a secured enclosure and protected from the weather, affecting 1 of 4 levels within the facility.

Findings include:

1. Observation made on January 15, 2019 at 1:05 pm, revealed their were 56 unprotected E-type portable oxygen cylinders being stored outdoors in carts on the ground floor loading dock.

Interview at the exit conference with the Administrator and the Maintenance Supervisor on January 15, 2019 at 2:50 pm, confirmed the unprotected portable oxygen cylinders.






 Plan of Correction - To be completed: 03/16/2019

The Central Supply Coordinator/Designee will bring empty oxygen tanks from the storage rooms (located on each unit) to the receiving area, and exchange them for full oxygen tanks upon oxygen tank delivery. No oxygen tanks will be stored outside.

Maintenance director or designee will ensure all E-type portable oxygen cylinders are properly secured and properly stored in the designated areas on each unit.
Maintenance director or designee will instruct staff on the proper storage and security of all E-type portable oxygen cylinders.
Maintenance director or designee will report findings in QAPI x 3 months, and as needed thereafter.


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