Nursing Investigation Results -

Pennsylvania Department of Health
PARKHOUSE REHABILITATION AND NURSING 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
PARKHOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  35 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.
PARKHOUSE REHABILITATION AND NURSING 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 March 12 - 13, 2019, it was determined that Parkhouse Rehabilitation And Nursing 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(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 March 13, 2019, revealed the facility was unable to provide an Emergency Preparedness plan that addressed patient/client population, persons at risk, and the type of services the facility has the ability to provide in an emergency.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 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: 05/10/2019

The Emergency Preparedness Plan has been updated to include policies and procedures to address the patient population.

Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

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 for subsistence needs for staff and residents during an emergency, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not include policies and procedures for provisions for subsistence needs for staff and residents, for the following:

a. Medical and pharmaceutical supplies;
b. Pharmaceutical supplies;
c. Temperatures to protect patient health and safety;
d. Sewage and waste disposal.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 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: 05/10/2019

The Emergency Preparedness Plan has been updated to include policies and procedures to ensure the subsistence needs for residents and staff concerning food, water, medical, pharmaceutical supplies and sewage and waste disposal.

Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

483.73(b)(6) REQUIREMENT Policies/Procedures-Volunteers and Staffing: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:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at 403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at 418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Name: - Component: -- - Tag: 0024

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan that included policies and procedures for the use of volunteers in an emergency or other staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not include policies for the use of volunteers in an emergency, to be reviewed and updated at least annually.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP plan did not include a policy for utilizing volunteers, in the event of an emergency.










 Plan of Correction - To be completed: 05/10/2019

Parkhouse will conduct a facility assessment utilizing volunteers in the approach for an emergency situation Facility will use the results of the assessment to further develop the Emergency Preparedness Plan that includes policies and procedures to include the use of volunteers in an emergency.

The Emergency Preparedness Plan has been updated to include a included policies and procedures for the use of volunteers in an emergency or other staffing strategies,

Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

Facility will implement the plan and conduct drills with volunteers.

The Safety and QAPI Committees will review at least annually.


483.73(c)(1) REQUIREMENT Names and Contact Information: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:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

Based on document review and interview, it was determined the facility failed to develop policies and procedures to include contact information for those individuals and entities outlined within the standard, as part of the Emergency Preparedness (EP) plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness communication plan did not include policies and procedures with contact information for the following entities, at the time of inspection, to be reviewed and updated at least annually.

a. Staff;
b. Other LTC facilities;
c. Volunteers.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed contact information for the EP plan was incomplete.










 Plan of Correction - To be completed: 05/10/2019

Facility will develop policies and procedures to include contact information for those individuals and entities outlined within the standard, as part of the Emergency Preparedness (EP) plan, affecting the entire facility.
Facility will update Emergency Preparedness plan to include contact information for the staff, other LTC facilities and volunteers.

Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

483.73(c)(2) REQUIREMENT Emergency Officials Contact Information: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:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at 483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, or local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at 483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.
Observations:
Name: - Component: -- - Tag: 0031

Based on document review and interview, it was determined the facility failed to ensure the Emergency Preparedness (EP) plan included a communication plan listing contact information for Federal, State, tribal, regional, and local emergency preparedness staff, affecting the entire facility.

Findings include:

1. Documentation reviewed on March 13, 2019, revealed contact information was not included in the Emergency Preparedness plan for the following:

Federal, State, and local emergency preparedness staff;
a. The Office of the State Long-Term Care Ombudsman;
b. Other sources of assistance.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP plan did not include all required contacts in the communication plan.






 Plan of Correction - To be completed: 05/10/2019

The Emergency Preparedness Plan has been updated to include contact information for the Office of the State Long-Term Care Ombudsman

Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

483.73(c)(3) REQUIREMENT Primary/Alternate Means for Communication: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:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at 483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Name: - Component: -- - Tag: 0032

Based on document review and interview, it was determined the facility failed to ensure the Emergency Preparedness plan included primary and alternate means for communication, affecting the entire facility.

Findings include:

1. Document review on March 13, 2019, revealed the Emergency Preparedness plan did not include primary and alternate means for communicating with the following:

a. Facility staff;
b. Federal, State, tribal, regional, and local emergency management agencies.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP did not include an alternate means for communication.









 Plan of Correction - To be completed: 05/10/2019

The Emergency Preparedness Plan has been updated to include primary and alternate method of communicating with staff, federal, state, tribal, regional and local emergency management agencies.

Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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.
[(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 a Communication plan for sharing information on occupancy needs, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not provide a Communication plan that included 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.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 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: 05/10/2019

The Emergency Preparedness Plan has been updated to include a Communication plan for sharing information on occupancy needs, affecting the entire facility.
Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

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 (EP) Communication plan for sharing plans and policies with family members, resident representatives, or clients, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not include a Communication plan demonstrating the method used for sharing information from the emergency preparedness plan with residents, clients or family members.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP plan did not include a method deemed appropriate for sharing information with families.






 Plan of Correction - To be completed: 05/10/2019

The Emergency Preparedness Plan has been updated to include a Communication plan for sharing plans and policies with family members, resident representatives, or clients, affecting the entire facility
Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

483.73(d) REQUIREMENT EP Training 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.
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at 483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. The ICF/IID must meet the requirements for evacuation drills and training at 483.470(h).

*[For ESRD Facilities at 494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be reviewed and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) training and testing program based on the emergency plan, risk assessment, policies and procedures, and communication plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not include a written program that specifically identified training in emergency preparedness for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP plan did not include a written initial training program.








 Plan of Correction - To be completed: 05/10/2019

The Emergency Preparedness Plan has been updated to include a written program that specifically identified training in emergency preparedness for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

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 develop an Emergency Preparedness (EP) testing program to conduct exercises to test the emergency plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not include a tabletop exercise that included 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.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP plan did not include testing of the emergency plan.




 Plan of Correction - To be completed: 05/10/2019

The Emergency Preparedness Plan has been updated to include a tabletop exercise to test the emergency plan at lease annually.
Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(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 the facility failed to develop policies and procedures in the Emergency Preparedness (EP) plan to maintain the Essential Electrical Systems operational for the duration of emergencies, as defined by the facilities emergency plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the Emergency Preparedness plan did not include policies and procedures to have emergency power systems or plans in place to maintain safe operations while sheltering in place, including maintaining an onsite fuel source.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed the EP plan did not include a means of maintaining emergency power systems, in the event of an emergency.








 Plan of Correction - To be completed: 05/10/2019

The Emergency Preparedness Plan has been updated to include policies and procedures to have emergency power systems or plans in place to maintain safe operations while sheltering in place, including maintaining an onsite fuel source.
Staff will be in-serviced on the new policies added to the Emergency Preparedness Plan.

The Safety and QAPI Committees will review at least annually.

Initial comments:Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0000


Facility ID # 133402
Component 01
Centers I and II

Based on a Medicare/Medicaid Recertification Survey conducted on March 12 - 13, 2019, it was determined that Parkhouse Rehabilitation And Nursing Center - Centers & II, 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 two story, Type II (000), unprotected non combustible construction, with a basement, which is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain carbon monoxide alarms in close proximity to fossil fuel-burning devices in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the carbon monoxide alarm locations included North Tower Dental, which no longer existed. The emergency/disaster manual emergency procedures requires updating and staff re in-servicing.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed carbon monoxide alarm policies and procedures required updating.







 Plan of Correction - To be completed: 05/10/2019

The Emergency Disaster Plan has been updated to remove the North tower dental

Staff will be in-serviced on the change in the emergency disaster manual.

The Safety and QAPI Committees will review at least annually.

NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to ensure doors in common fire walls maintained their fire resistance, affecting two of three components within the facility.

Findings include:

1. Observation made on March 12, 2019, at 9:25 am, revealed the rated double doors located in the basement common wall that separate the West and Center Buildings had missing end caps, and the panic bar was loose from the door.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the condition of the fire door.


2. Observation made March 12, 2019, at 11:00 am, revealed the basement common wall fire doors separating Center I and Center II from the East Building, required adjustment to close and latch in proper sequence.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the doors failed to close completely and positively latch.







 Plan of Correction - To be completed: 05/10/2019

Observation#1
The rated double doors have been repaired by replacing panic bar end caps with proper rated caps and we will tighten the panic bar mounts.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

Observation#2
The basement common wall fire door closure has been adjusted, and latching hardware has been inspected and tested for proper operation.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

NFPA 101 STANDARD Means of Egress - General:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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 (CENTER 1 & 2) - Component: 01 - Tag: 0211

Based on observation, document review and interview, it was determined the facility failed to ensure exit egress was so arranged that exits were readily accessible at all times, affecting four of four smoke compartments within this component.

Findings include:

1. Observation and documentation reviewed on March 12, 2019, between 10:30 a.m. and 1:45 p.m., revealed the clear headroom in the corridor in the basement of the Center I Building was approximately six feet three inches, which was below the minimum requirement of six feet eight inches.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the basement corridor headroom.




 Plan of Correction - To be completed: 05/10/2019

Letter was submitted to
Division of Life Safety for
consideration regarding this
concern.
Parkhouse Nursing and
Rehabilitation Center would like to request a Time-Limited Waiver (TLW) for deficiency in building 1
(Center wing 0211):
(Center wing) 0211: The facility
"clear head room in basement " is
currently six feet three inches and is now required to be six feet eight inches, as identified on the recent Department of Health Life Safety Survey completed on 03/13/19
The facility plans to explore options to correct the deficient practice: We will engage engineering and architectural services to consult on options to comply with the new life safety standards. Then if a feasible solution is identified we will implement it.

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 (CENTER 1 & 2) - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to ensure the fire resistance rating of stair tower enclosures was maintained, affecting one of three floors within this component.

Findings include:

1. Observation made on March 12, 2019, at 9:25 am, revealed the fire resistance label on the 1st floor stair tower 5 corridor access door was not clear enough to read.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the fire resistance labeling was difficult to read.










 Plan of Correction - To be completed: 05/10/2019

The fire resistance label on the 1st floor for stair tower 5 has been corrected, the label is legible and can be read.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions. Checking the fire resistance lables has been added to this.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0271

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

Findings include:

1. Observation made on March 12, 2019, at 10:00 am, revealed the 1st floor exit door by the MPR mechanical room and activities, which discharges to the outside of the building, required excessive force to open.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the door required excessive force to open.














 Plan of Correction - To be completed: 05/10/2019

The door by the MPR mechanical room has been repaired ensuring proper gap between doors to keep from binding, and adjust the closure in order for the door to properly operate.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.


NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 (CENTER 1 & 2) - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit directional signs along the means of egress, affecting one of four smoke compartments within this component.

Findings include:

1. Observation made on March 12, 2019, at 10:30 am, revealed the first floor exit directional sign did not clearly indicate the common path of travel, and the direction of egress.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the exit sign was not maintained.








 Plan of Correction - To be completed: 05/10/2019

The first floor exit sign directional sign has been updated to clearly indicate the common path of travel, and the direction of egress.
Parkhouse has a Tels monitoring system has been update to include the review of all exit directional signs, Maintenance personnel will perform
Routine checks of the signage to ensure a common path of travel is indicated.

Findings will be reviewed at Quarterly QAPI Meeting.

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 (CENTER 1 & 2) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the integrity of the ceilings, which could prevent activation of the sprinkler system, affecting one of four smoke compartments within this component.

Findings include:

1. Observation made on March 12, 2019, at 10:45 am, revealed in the basement telephone room, there were ceiling tiles missing from the suspended ceiling assembly.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the condition of the ceiling.







 Plan of Correction - To be completed: 05/10/2019

The missing ceiling tiles in the phone room were replaced. All ceiling tiles in this room will be inspected and the maintenance team will assure they are smoke tight. Parkhouse implemented a monthly Tels monitoring system requirement that will generate a work order to inspect an area of the facility for missing, broken, or damaged ceiling tiles and replace them as needed.

Every area of the building will require maintenance personnel to perform routine checks and repair or replace as needed.

Findings will be reviewed at Quarterly QAPI Meeting.

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 (CENTER 1 & 2) - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain required testing of electrical receptacles, affecting the entire healthcare campus.

Findings include:

1. Documentation reviewed on March 13, 2019, revealed electrical receptacles at patient 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 for hospital grade receptacles based on documented performance data or 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, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 p.m., confirmed testing of electrical receptacles was not provided.











 Plan of Correction - To be completed: 05/10/2019

The maintenance team will develop a master floor plan with style, type, and location of all outlets that are required to be inspected, including patient bed locations and in locations where deep sedation or general anesthesia is administered.
The Facilities Director will develop a master outlet log and implement in the Tels monitoring system a work order to inspect and test the outlets in a designated area of the facility identified by the master floor plan.
This testing will be completed annually, minimally not exceeding 12 months.

Initial comments:Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0000


Facility ID# 133402
Component 02
North Building

Based on a Medicare/Medicaid Recertification Survey conducted on March 12 - 13, 2019, it was determined that Parkhouse Rehabilitation And Nursing Center - North Building, 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 an eight story, Type II (222), fire resistive construction, with a basement and penthouses, which is fully sprinklered.









 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0100

Based on observation and interview, it was determined the facility failed to secure plan approval by the Department of Health prior to initiating alterations and renovations, affecting the entire facility.

Findings include:
1. Observation and interview on March 12, 2019, at 2:47 pm, revealed there was evidence of renovations being performed on the 4th floor of the North Building. Observations included areas that were stripped of finishes and being re-painted, multiple patient rooms were missing doors, metal patient room door frames exhibited an unknown filler putty that was applied to dents in the frames. There was part of the 4th floor where the electricity was not functioning even when turning on the appropriated circuit breakers.
Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the facility failed to secure plan approval by the Department of Health prior to initiating renovations within the facility.

28 Pa Code 51.3. Notification (d)









 Plan of Correction - To be completed: 05/10/2019

North building 4th floor unit was having cosmetic updating done, no structural changes. The patient room doors have been hung and functioning properly The corner protectors were removed, the frames were sanded and primed. The electricity on the unit is functioning properly.
NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of doors in common fire walls, affecting 1 of 9 levels within the component.

Findings include:

1. Observation made on March 12, 2019, at 9:34 am, basement North Building, revealed the rated double doors in the basement common wall separating the North and Center Building had an approximately one-half inch wide by three inch long gap where the doors leaves meet near the door handle.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the gap in the rated double common wall doors.







 Plan of Correction - To be completed: 05/10/2019






The North basement double doors have been repaired to correct the gap.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.


NFPA 101 STANDARD Building Construction Type and Height: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.
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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the fire-resistance rating of the building, affecting 1 of 16 smoke zones within this component.

Findings include:

1. Observations made on March 12, 2019, between 9:55 am and 9:58 am, North Building, revealed an unknown expanding spray foam material was used to seal gaps and penetrations in the following locations:

a. 9:55 am, 1st floor, above both sides of the rated doors to the main laundry room, a wire penetration;
b. 9:58 am, 1st floor, above both sides of the door to the sewing room located within the main laundry room, there was a large gap.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed an unknown expanding spray foam material was used in the above named locations.







 Plan of Correction - To be completed: 05/10/2019

The expanding spray foam was removed from the North building areas identified
----The wire penetration was sealed according to UL System number W-J-3046, using the systems approved product.
---- The gaps above the sewing room door have been re-framed and sheet rocked using 5/8" sheet rock. Any gaps not being covered by the sheet rock will be sealed according to UL System number HW-D-0519, using the systems approved product.
To prevent future penetrations, Parkhouse implemented a Fire/Smoke Barrier Penetration permit (agreement for outside contractors doing work in the facility). This will require all employees and contractors to describe the work being performed and require a post inspection by facilities to ensure that all walls and penetrations, if any, have been properly sealed. All penetrations will be sealed according to UL approved systems for that specific penetration.

Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure exit egress was so arranged that exits were readily accessible at all times, affecting 1 of 9 levels within this component.

Findings include:

1. Observation made on March 12, 2019, at 1:22 pm, North Building, revealed in the 2nd floor corridor across from resident room 213, the stair tower door was obstructed by wheelchairs and carts.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the stair tower door was obstructed.





 Plan of Correction - To be completed: 05/10/2019

The wheel chairs and carts have been removed from obstructing the stair tower door.
Nursing staff will monitor the stair tower door to ensure no obstructions are present.
Staff will be reeducated on fire safety and maintaining a clear exit path, not to obstruct stair tower doors.

Findings will be reviewed at Quarterly QAPI Meeting.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors located in exit passageways, affecting 1 of 9 levels within the component.

Findings include:

1. Observation made on March 12, 2019, at 9:45 am, basement North Building, revealed the door to the chemical storage/wheel chair washing room, located in an exit passageway, failed to self-close and positively latch into the frame.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the door failed to self-close and positively latch.





 Plan of Correction - To be completed: 05/10/2019

The wheel chair washroom door was repaired by adjusting the latches and closures to allow the door to properly close and latch.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0281

Based on observation and interview, it was determined the facility failed to maintain continuous illumination along the means of egress, affecting 1 of two exit stair towers within this component.

Findings Include:

1. Observation made on March 12, 2019, at 9:03 a.m., revealed there were non-operable light bulbs inside the top of the east stairtower, leading to the penthouse, North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed egress lighting was not illuminated.




 Plan of Correction - To be completed: 05/10/2019

The light bulbs in the stair tower have been replaced.
Facility will maintain continuous illumination along the means of egress, maintenance staff will check stair tower lighting monthly to ensure all stairwell tower light are in in working order.
Findings will be reviewed at Quarterly QAPI Meeting.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0311

Based on observation and interview, it was determined the facility failed to ensure to vertical openings maintain a fire resistance rating between floors, affecting the entire building component.

Findings include:

1. Observations and documentation reviewed on March 12, 2019, revealed electrical panel box LP 81, penetrate the building service shaft enclosure on the eighth floor. This condition was noted throughout the component, in all electrical panel boxes, penetrating both building service shaft enclosures on all floors.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the vertical openings lacked a fire-resistive integrity.


2. Observation made on March 12, 2019, at 9:07 am, basement North Building, revealed inside the fire pump/sprinkler riser room, the rated door to the large mechanical chase room failed to positively latch.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the door failed to latch.

3. Observation on March 12, 2019, at 9:50 a.m., revealed inside the tub room across from room 809, behind the tub access panel, there was an opening through the floor that could be seen toward the east corridor, revealing the top of the suspended ceiling below.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the fire rated integrity of the ceiling/floor assembly were not maintained.






 Plan of Correction - To be completed: 05/10/2019

1.The facility requests the Department of Health conduct an FSES for this deficiency; A Time Limited Waiver has been submitted for completion of alternative correction, if required, by 11/01/2021
2 The basement chase door was repaired to ensure it positively latches.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.
3 The penetration was sealed according to UL System number W-L-1049, using the systems approved product. To prevent future penetrations, Parkhouse implemented a Fire/Smoke Barrier Penetration permit (agreement for outside contractors doing work in the facility). This will require all employees and contractors to describe the work being performed and require a post inspection by facilities to ensure that all walls and penetrations, if any, have been properly sealed. All penetrations will be sealed according to UL approved systems for that specific penetration.
Every month the Tels monitoring system will generate a work order to check for penetrations on a random floor of the facility.
This information will then be entered into the Tels system and a log will be created in the system for QA purposes.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures with a smoke tight resistance, in sprinklered locations, affecting 3 of 9 levels within the component.

Findings include:

1. Observation made on March 12, 2019, at 9:57 am, North Building, revealed both leaves of the rated double doors to the 1st floor main laundry room had missing end caps on the rated panic hardware.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the end caps were missing.


2. Observations made on March 12, 2019, between 10:15 am and 10:26 am, North Building, revealed doors to hazardous areas failed to positively latch into their frames, in the following locations:

a. 10:15 am, 1st floor, both leaves of the rated double doors to the north electrical storage room;
b. 10:26 am, 1st floor, both leaves of the rated double doors to the large medical records storage room.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the doors failed to latch in the above named locations.


3. Observation made on March 12, 2019, between 1:20 p.m. and 1:40 p.m., revealed there were soiled linen carts housed inside tub rooms. The tub room corridor doors lacked self-closures and positive self-latching hardware:

a. 1:20 p.m, across from room 703, 7 North;
b. 1:34 p.m., across from room 623, 6 North;
c. 1:40 p.m., across room 610, 6 North.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the tub room was not protected as a hazardous area.









 Plan of Correction - To be completed: 05/10/2019

1 The laundry double doors were repaired by replacing the end caps with approved fire rated end caps.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.

Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

2.Doors identified in this tag have been repaired to ensure they positively latch into their frames.

3.Soiled linen carts have been removed from inside the tub rooms.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.

Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.

Findings will be reviewed at Quarterly QAPI Meeting.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain a smoke resistive ceiling assembly near smoke detectors, which could delay activation of the fire alarm device, affecting 1 of 16 smoke zones within the component.

Findings include:

1. Observation made on March 12, 2019, at 8:55 am, Basement North Building, revealed a large gap in a suspended ceiling tile next to a smoke detector in the corridor in front of the double elevators.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the gap near a smoke detector.






 Plan of Correction - To be completed: 05/10/2019

The ceiling tile identified have been replaced to fill the gap. All ceiling tiles will be inspected and maintenance team will assure they are smoke tight.
Parkhouse implemented a monthly Tels monitoring system requirement that will generate a work order to inspect an area of the facility for missing, broken, or damaged ceiling tiles and replace them as needed. The system will automatically generate the work order on a monthly basis. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tells monitoring system, which generates a log for tracking and QA purposes.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure the automatic sprinkler system were inspected at required intervals, affecting the entire building component.

Findings include:

1. Observation made on March 12, 2019, at 9:00 am, basement North Building, revealed inside the wet sprinkler pump/riser room, there were two gauges located near the fire pump jockey and fire pump controller wall mounted boxes dated 2013. The facility could not provide documentation the two gauges were calibrated within the previous 5 years.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the sprinkler system gauges were expired.






 Plan of Correction - To be completed: 05/10/2019

Outside Contractor- Company has been contacted to replace the two gauges that were missed during our 5 year sprinkler inspection.
All future work by contractors will be reviewed by the Maintenance Director or appointed Supervisor to ensure the job has been fully completed prior to the contractor leaving the facility.

Appropriate paperwork will be obtained and kept in the maintenance office files.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in proper operating condition, affecting 1 of 16 smoke zones within this component.

Findings include:

1. Observation made on March 12, 2019, at 10:02 am, 1st floor North Building, revealed a wall mounted portable fire extinguisher located next to the stair tower door inside the main laundry. The gauge indicated the extinguisher was in a discharged state.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the extinguisher was in a discharged state.







 Plan of Correction - To be completed: 05/10/2019

The fire extinguisher located on the 1st floor North Building has been replaced. Parkhouse implemented a monthly Tels monitoring system requirement that will generate a work order to inspect all fire extinguishers in the facility for missing, broken, damaged, or discharged extinguishers and replace them as needed. The system will automatically generate the work order on a monthly basis. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tells monitoring system, which generates a log for tracking and QA purposes
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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors positively latched into the door frame, affecting 3 of 16 smoke zones within this component.

Findings include:

1. Observation made on March 12, 2019, at 9:42 a.m., revealed there was a gap between the clean linen room corridor double doors across from room 809, exceeding 1/8 inch. In addition, the door handle was loose, 8th floor North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the corridor door was not smoke tight in its frame.


2. Observation made on March 12, 2019, between 1:05 p.m. and 1:44 p.m., revealed the following solarium room corridor double doors would not positively self-latch into their frames:

a. 1:05 p.m., west side, 7 North Building;
b. 1:24 p.m., next room room 714, 7 North Building;
c. 1:44 p.m., across from room 609, 6 North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the corridor doors required adjustment.

3. Observation made on March 12, 2019, at 1:28 pm, 3rd floor North Building, revealed the corridor door to resident room 311 failed to positively latch into the frame.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the door failed to latch.












 Plan of Correction - To be completed: 05/10/2019

1 The N8 clean linen door gap has been repaired. Door handle was tightened

2. All doors identified in this
tag have been repaired by adjusting the
latches and closures in order for the
door to properly close and latch.

3.The N311 door have been repaired by adjusting the door components to ensure they positively latch into the frame.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier partitions with a fire resistance rating, affecting 4 of 16 smoke compartments.

Findings Include:

1. Observation made on March 12, 2019, between 9:42 a.m. and 1:18 p.m., revealed there were openings and penetrations in smoke barrier partitions, at the following locations:

a. 9:42 a.m., inside the janitor's closet, across from room 806, 8 North Building;
b. 1:16 p.m., inside the janitor's closet, across from room 706, 7 North Building;
c. 1:18 p.m, across from the nurse station next to the elevators, 7 North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed there were smoke barrier openings/penetrations.





 Plan of Correction - To be completed: 05/10/2019

All penetrations in this tag have been sealed according to UL System number W-J-3025, using the systems approved product.
To prevent future penetrations, Parkhouse implemented a Fire/Smoke Barrier Penetration permit (agreement for outside contractors doing work in the facility).
This will require all employees and contractors to describe the work being performed and require a post inspection by facilities to ensure that all walls and penetrations, if any, have been properly sealed. All penetrations will be sealed according to UL approved systems for that specific penetration. Every month the Tels monitoring system will generate a work order to check for penetrations on a random floor of the facility.
This information will then be entered into the Tels system and a log will be created in the system for QA purposes

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0521

Based on document review and interview, it was determined the facility failed to ensure fire dampers were properly installed, affecting 1 of nine levels within this component.

Findings include:

1. Observation and documentation reviewed on March 12, 2019, revealed fire dampers installed inside ductwork that penetrates the building services shaft on the fourth floor, were not installed in a sleeve or frame, secured by perimeter-mounting angles on both sides of the shaft opening. Mounting angles were only installed on the outside or habitable side of the shaft.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the fire damper installation was incomplete.











 Plan of Correction - To be completed: 05/10/2019

Fire Damper inspection was previously performed by outside contractor, documentation received with no deficiencies noted.
Facility staff perform annual visual inspection.
Findings will be reviewed at Safety & QA Meeting

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0522

Based on observation and interview, it was determined the facility failed to ensure combustible materials were not placed on heating devices, affecting 5 of 9 levels within the component.

Findings include:

1. Observations made on March 12, 2019, between 9:16 a.m. and 2:45 pm, North Building, revealed combustible materials placed on top of or housed beneath heating unit vents, at the following locations:

a. 9:16 a.m., 8th floor, trash beneath the corridor heating unit, outside room 813;
b. 9:16 a.m., 8th floor, resident room 812, a pillow on top;
c. 9:17 a.m., 8th floor, resident room 811, diapers on top;
d. 10:45 am, 2nd floor, resident room 224, cloth and paper material on top;
e. 10:47 am, 2nd floor, resident room 223, cloth material on top;
f. 10:50 am, 2nd floor, resident room 222, paper on top;
g. 1:25 pm, 3rd floor, resident room 313, cloth material on top;
h. 1:34 p.m., 6th floor, resident room 617, plush animals on top;
i. 1:35 pm, 3rd floor, resident room 306, cloth material on top;
j. 1:38 pm, 3rd floor, resident room 302, cloth material on top;
k. 1:39 pm, 3rd floor, resident room 301, cloth material on top;
l. 1:50 p.m., 5th floor, resident room 522, dolls on top;
m. 2:45 pm, 3rd floor, resident room 318, cloth material on top.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed combustibles were placed near heating devices in the above named locations.








 Plan of Correction - To be completed: 05/10/2019

Combustible items will be removed from the induction /heating unit vents.
Staff will monitor resident rooms for placement of personal items to ensure combustible materials are not placed on/under induction/ heating devices.
Results will be reviewed at Qtrly QAPI

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating for laundry chute enclosures, affecting 1 of 9 levels within the component.

Findings include:

1. Observation made on March 12, 2019, at 1:20 pm, revealed the rated corridor door to the 2nd floor laundry chute room failed to positively latch.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the door failed to latch.








 Plan of Correction - To be completed: 05/10/2019

The 2nd floor laundry chute door was adjusted to ensure proper latch.

Parkhouse has implemented a monthly fire door inspection for all fire door assemblies to ensure they close and latch in accordance with NFPA 80. Standard requires that all shall be maintained and if broken shall be repaired or replaced. Every area of the building will get a slip which requires maintenance personnel to perform the checks and sign off on these items. They are then turned into maintenance and the Facilities Director or Maintenance Supervisor checks the item complete in the system which generates a log for tracking.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0712

Based on observation, document review and interview, it was determined the facility failed to conduct fire drills per regulations, affecting the entire healthcare campus.

Findings Include:

1. Observations and documentation reviewed on March 12, 2019, between 10:30 a.m. and 12:00 p.m., revealed during activation of a fire drill, staff were not familiar with the procedures. Although some personnel initiated the Rescue Alarm Confine Extinguish (R.A.C.E) process, some personnel did not. Corridors were not cleared of equipment, nor were corridor doors closed. Many residents remained in the corridors throughout the drill. Fire drill documentation reviewed also revealed very weak or poor responses by personnel. The above was noted on the 8th, 7th, and 6th floors, North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 pm, confirmed fire drill procedures were not applied by all staff.


2. Documentation reviewed on March 13, 2018, revealed fire drills were conducted within the same time frame for the 2nd and 3rd shifts, as follows:

a. 2nd Shift - between 4:30 a.m. and 5:30 a.m.
4:29 p.m. on 3/22/18, 5:14 p.m. on 6/29/18, and 4:53 p.m. on 9/20/18;

b. 3rd shift - between 1:45 p.m. and 2:15 p.m.
2:15 p.m. on 4/22/18, 2:15 p.m. on 7/7/18, and 1:45 p.m. on 10/18/18.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 pm, confirmed fire drills were not conducted at unexpected times.










 Plan of Correction - To be completed: 05/10/2019

Facility immediately trained all staff
that were in the building.
Weekly Fire drills are being conducted on various shifts,
Ongoing education to all staff regarding fire safety education.
First time agency staff continue to
take part in fire safety education
prior to being assigned a unit.
On the spot education being conducted during the drills to ensure understanding.

Facility will continue to monitor and present result at QAPI meeting.

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0754

Based on observation and interview, it was determined the facility failed to properly store soiled linen receptacles, affecting 2 of 9 levels within the component.

Findings include:

1. Observation on March 12, 2019, between 10:48 am and 1:30 pm, North Building, revealed improperly stored soiled linen receptacles in the following locations:

a. 10:48 am, 3rd floor, six filled 32 gallon soiled linen containers, with a combined capacity of 192 gallons were being stored inside the tub room that is located across from resident room # 310;
b. 1:30 pm, 2nd floor, four filled 32 gallon soiled linen containers, a combined capacity of 128 gallons was being stored inside the women's toilet room that is located across from resident room # 223.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the soiled linen receptacles were improperly stored in the above named locations.






 Plan of Correction - To be completed: 05/10/2019

Soiled linen containers were removed from the tub rooms to be properly stored.
Nursing staff will monitor units to ensure soiled linens are being stored properly.
Findings will be reviewed at safety and QA meeting

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance Pr: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 and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0907

Based on document review and interview, it was determined the facility failed to maintain medical gas systems in fully operable condition, affecting 1 of nine levels within this component.

Findings Include:

1. Documentation reviewed on March 13, 2019, revealed the medical gas documentation report dated February 21, 2019 indicated a leak at 422S.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 pm, confirmed there was a deficient condition of the medical gas system.







 Plan of Correction - To be completed: 05/10/2019

The leak in N422 has been fixed by replacing the metering valve with a new one.
All future work by contractors will be reviewed by the Maintenance Director or appointed Supervisor to ensure the job has been fully completed prior to the contractor leaving the facility.
Parkhouse has a Tels monitoring system requirement that assigns a work order to check all doors for closure, positive latching and gaps, locks, alarms, hardware inspection, to repair any deficiencies found, and to ensure the areas around the doors are clear from obstructions.
Every area of the building will get will require maintenance personnel to perform the checks and sign off on these items.
Findings will be reviewed at Quarterly QAPI Meeting.


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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect electrical system wiring in accordance with NFPA 99 2012 Edition, 6.3.2.1 Electrical Installation, in three instances, affecting 2 of 16 smoke zones within the component.

Findings include:

1. Observation made on March 12, 2019, at 8:55 a.m., revealed penthouse elevator 7 electrical controls were exposed. The doors marked High Voltage were in the open position, North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the electrical equipment was unprotected.

2. Observation made on March 12, 2019, at 9:28 am, basement North Building, revealed inside the fire pump/sprinkler riser room, a junction box mounted on the column near the air handler gauge panel was missing a cover, exposing the wiring.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the junction box was missing a cover.

3. Observation made on March 12, 2019, at 9:07 a.m., revealed there was an abandoned electrical device (bug zapper) secured above the suspended ceiling outside room 813, 8th floor North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the electrical device was housed above the ceiling.






 Plan of Correction - To be completed: 05/10/2019

1 The elevator penthouse electrical doors have been closed.
Parkhouse will place written instructions for the elevator contractors inside the elevator key sign out log at Security so when the elevator company signs the keys in and out they will also be acknowledging that the electrical doors must also be shut after work is completed. Security will make routine rounds to the penthouses to ensure the doors are secure when not one is in the vicinity.

2.The junction box cover was replaced with correct manufactures cover. An inspection of all electric boxes will be completed to assure they are all properly covered and protected.
Parkhouse will implement a Bi- monthly Tels monitoring system requirement that will generate a work order to inspect an area of the facility for exposed wires and unsecured junction boxes. Maintenance will correct the deficiency or have the Facilities Director and or Maintenance Supervisor call in the appropriate contractor for repairs. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tels monitoring system, which generates a log for tracking for QA purposes.
3. The abandoned bug zappers have been removed. All future work by contractors will be reviewed by the Maintenance Director or appointed Supervisor to ensure the job has been fully completed prior to the contractor leaving the facility to ensure no unapproved items are utilized.

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0921

Based on observation and interview, it was determined electrical receptacles were not maintained in safe operating condition, in two instances, affecting 1 of nine levels within this component.

Findings Include:

1. Observation made on March 12, 2018, at 9:28 a.m., revealed inside resident room 810, near the resident window bed, there was a burned wall mounted electrical receptacle, North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the electrical receptacle was not maintained in proper operating condition.


2. Observation made on march 12, 2018, between 9:28 a.m. and 10:30 a.m., revealed there was a metal key-like object protruding from the electrical wall outlet, inside resident room 806, 8 North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the electrical receptacle had been compromised.




 Plan of Correction - To be completed: 05/10/2019

Electrical receptacles have been replaced in both rooms identified on North 8 Unit with hospital grade outlets.
Parkhouse will implement a monthly area audit for electrical outlets, in Tels, to align with and meet the new Life Safety requirements for outlet testing. The Tels system will automatically generate a work slip to check a specific area of the building until all outlets have been checked and the yearly Life Safety requirement has been met. Maintenance will correct the deficiency or have the Facilities Director and or Maintenance Supervisor call in the appropriate contractor for repairs. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tels monitoring system, which generates a log for tracking for QA purposes

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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure portable oxygen storage holding enclosures had required signage posted, in 7 instances, affecting 4 of 16 smoke zones within the component.

Findings include:

1. Observation made on March 12, 2019, at 1:00 p.m., revealed there were boxes stored within 5-feet of E-type oxygen cylinders, inside the east side closets, 8th, 7th, and 6th floors, North Building.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed gas cylinder storage was housed near combustible materials.


2. Observation made on March 12, 2019, at 1:12 pm, North Building, revealed inside the 2nd floor north portable oxygen storage closet, empty/full signage was not posted for eleven E Type portable oxygen cylinders stored in the closet.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the required signage was not posted.


3. Observation made on March 12, 2019, between 1:45 p.m. and 2:30 p.m., revealed the following gas cylinder storage deficiencies:

a. the large exterior oxygen cylinder shed was not locked;
b. there was a free-standing H-size oxygen cylinder housed inside the exterior storage shed;
c. there were 16 H-size oxygen cylinders, part of the manifold system, inside the bulk tank gated enclosure, that were not protected from inclement weather conditions.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed gas cylinder storage was not supported from falling nor secured against unauthorized entry and weather.







 Plan of Correction - To be completed: 05/10/2019

1 Boxes have been removed from the east side closets on the 6th 8th floors in the North building.
Parkhouse will implement a monthly Tels monitoring system requirement that will generate a work order to inspect all oxygen storage rooms for stored items and missing signage and remove or replace as needed. The system will automatically generate the work order on a monthly basis. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tels system, which generates a log for tracking for QA purposes.

2. Storage area in the North Building, 2nd floor has been labeled with proper signage to identify full/empty portable oxygen
Parkhouse will implement a monthly Tels monitoring system requirement that will generate a work order to inspect all oxygen storage rooms for stored items and missing signage and remove or replace as needed. The system will automatically generate the work order on a monthly basis. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tels system, which generates a log for tracking for QA purposes.
3 a Large exterior oxygen cylinder shed has been secured.
b.The freestanding h-cylinder has been removed from the exterior shed.
c. Facility has on file construction plans from the O2 pad that were previously reviewed and approved by Life Safety

Initial comments:Name: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0000


Facility ID # 133402
Component 03
West Building

Based on a Medicare/Medicaid Recertification Survey completed on March 12 - 13, 2019, it was determined that Parkhouse Nursing 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 483.90(a).

This is a three story, Type II (000), unprotected non-combustible building, with a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0133

Based on observation and interview, it was determined the facility failed to ensure doors in common fire walls were maintained, in two of three components within the facility.

Findings include:

1. Observation made on March 12, 2019, at 9:25 am, revealed the rated double doors located in the basement common wall separating the West from the Center Building had missing end caps, and the panic bar was loose from the door.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the condition of the fire door.




 Plan of Correction - To be completed: 05/10/2019

The basement double doors have been repaired with proper hardware. Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check all doors for closure, positive latching and gaps, locks, alarms, and to repair any deficiencies found and to ensure the areas around the doors are clear from obstructions. Every area of the building will get a slip which requires maintenance personnel to perform the checks and sign off on these items. They are then turned into the Tels Coordinator and the Maintenance Supervisor checks the item complete in the system which generates a log for tracking and QA purposes.
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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain stair tower doors, affecting one of three stair towers.

Findings include:

1. Observation on March 12, 2019, at 9:55 am, revealed, the basement stair tower 11 was missing a fire rating label and the frame was rusted through in areas.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the condition of the rated door assembly.




 Plan of Correction - To be completed: 05/10/2019

An outside contractor has been contacted to measure the door and frame assembly. Order has been placed for the basement stair tower door identified in this tag, Parkhouse maintenance staff will ensure proper installation is completed and labeled upon arrival of the doors.
Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check all fire doors for closure, positive latching and gaps, locks, alarms, tags, and to repair any deficiencies found and to ensure the areas around the doors are clear from obstructions. Every area of the building will get a slip which requires maintenance personnel to perform the checks and sign off on these items. They are then turned into the Tels Coordinator and the Maintenance Supervisor checks the item complete in the system which generates a log for tracking and QA purposes.

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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0311

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

Findings include:

1. Observation on March 12, 2019, at 10:15 am, revealed, in the basement room 35, there was an unsealed penetration of the ceiling assembly by the desk.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the unsealed vertical penetration.




 Plan of Correction - To be completed: 05/10/2019

The penetration has been sealed according to UL System number W-J-3043, using the systems approved product. To prevent future penetrations, Parkhouse implemented a Fire/Smoke Barrier Penetration permit (agreement for outside contractors doing work in the facility). This will require all employees and contractors to describe the work being performed and require a post inspection by facilities to ensure that all walls and penetrations, if any, have been properly sealed. All penetrations will be sealed according to UL approved systems for that specific penetration. Every month the Tels monitoring system will generate a work order to check for penetrations on a random floor of the facility. This information will then be entered into the Tels system and a log will be created in the system for QA purposes.
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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure kitchen equipment was inspected, in two instances, affecting 1 of four levels.

Findings include:

1. Observation made on March 12, 2019, at 10:45 am, revealed, inside Dietary, the kitchen suppression tag was missing the February 2019 monthly quick-check inspection.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the missing quick check.


2. Documentation reviewed on March 13, 2019, revealed the kitchen equipment inspection report dated March 20, 2018, indicated the fryer pulls, gas, solenoid were not tested.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 13, 2019, at 2:30 pm, confirmed kitchen equipment components required inspection.








 Plan of Correction - To be completed: 05/10/2019

Quick check tags have been inspected. All fire suppression systems have been added to the monthly inspection list. Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check the fire suppression systems, sign off quick check tags, and have any repairs needed be performed by a qualified contractor. Every area of the building will get a slip which requires maintenance personnel to perform certain checks and sign off on these items. They are then turned into maintenance and the Facilities Director or Maintenance Supervisor checks the item complete in the system which generates a log for tracking.

2 Outside Vendor contacted, Inspection performed on equipment and tested.
Equipment will be added to the TELS system for scheduled maintenance and inspection.

NFPA 101 STANDARD Smoke Detection: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.
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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors in operable condition, affecting one of four floors.

Findings include:

1. Observation on March 12, 2019, at 1:45 pm, revealed, inside the 3rd floor Unit Manager ' s office, a smoke detector was detached from its housing.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the detached smoke detector.




 Plan of Correction - To be completed: 05/10/2019

The smoke detector on 3rd floor inside Unit Managers office has been remounted to the housing.
Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check the fire suppression systems, sign off quick check tags, and have any repairs needed be performed by a qualified contractor. Every area of the building will get a slip which requires maintenance personnel to perform certain checks and sign off on these items. They are then turned into maintenance and the Facilities Director or Maintenance Supervisor checks the item complete in the system which generates a log for tracking.

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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0353

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

Findings include:

1. Observation made on March 12, 2019, at 10:20 am, revealed, in the basement, stair tower 10, the wiring at the flow switch was left exposed and unprotected.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the unsecured wiring at the flow switch.


2. Observations made on March 12, 2019, between 11:50 am, and 1:40 pm, revealed sprinklers with a buildup of dust and debris, in the following locations:

a. 11:50 am, kitchen walk in cooler;
b. 1:40 pm, 3rd floor room 312.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the buildup on the sprinklers.




 Plan of Correction - To be completed: 05/10/2019

A proper wiring cover was installed in the basement stair tower 10 to maintain protection of the sprinkler components.
Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check the fire suppression systems, sign off quick check tags, and have any repairs needed be performed by a qualified contractor. Every area of the building will get a slip which requires maintenance personnel to perform certain checks and sign off on these items. They are then turned into maintenance and the Facilities Director or Maintenance Supervisor checks the item complete in the system which generates a log for tracking.

Sprinklers identified have been cleaned by maintenance staff, Outside Contractor was contacted to replace those that need to be replaced.
Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check the fire suppression systems, sign off quick check tags, and have any repairs needed be performed by a qualified contractor. Every area of the building will get a slip which requires maintenance personnel to perform certain checks and sign off on these items. They are then turned into maintenance and the Facilities Director or Maintenance Supervisor checks the item complete in the system which generates a log for tracking.

NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0761

Based on observation and interview, it was determined the facility failed to ensure rated door assemblies were maintained, affecting two of four building levels.

Findings include:

1. Observation made on March 12, 2019, at 9:45 am, revealed, the basement freight elevator rated door would not close and latch; there was a hole in the door, and the frame was pulling away from the wall.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the condition of the rated door assembly.


2. Observation on March 12, 2019, at 9:50 am, revealed, in the basement, the room located under dietary, the fire door to the crawl space was detached from its frame and resting on the floor.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the detached fire door.


3. Observation on March 12, 2019, at 10:40 am, revealed the rating label on the doors separating kitchen and dining room was painted over and illegible.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the illegible rating label.




 Plan of Correction - To be completed: 05/10/2019

The basement freight elevator door has been adjusted to close and latch, the hole was patched with UL approved SpecSeal LCI Intumescent Sealant.

2 The crawl space fire door was re-hung and checked to ensure proper operation.

3 Maintenance staff removed the paint from the area of the door to reveal the fire rating label and make it legible.

Parkhouse has implemented a Tels monitoring system requirement that assigns a work order every month to check all doors for closure, positive latching and gaps, locks, alarms, and to repair any deficiencies found and to ensure the areas around the doors are clear from obstructions. Every area of the building will get a slip which requires maintenance personnel to perform the checks and sign off on these items. They are then turned into the Tels Coordinator and the Maintenance Supervisor checks the item complete in the system which generates a log for tracking and QA purposes.

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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting one of four building levels.

Findings include:

1. Observation on March 12, 2019, at 9:50 am, revealed, in the basement, the room located under dietary, there was a large electrical trough with exposed internal wiring.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the exposed wiring.


2. Observation on March 12, 2019, at 10:10 am, revealed a loose electrical panel cover in basement corridor by the west pump room. The cover was loose due to missing screws at the top.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the loose panel cover.


3. Observation on March 12, 2019, at 1:25 pm, revealed, on the 3rd floor, the corridor above the suspended ceiling by stair tower 7, there was a junction box with a missing cover plate and exposed internal wiring.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the missing cover plate.

Refer to the NFPA 70 National Electrical Code, Section 300.31.





 Plan of Correction - To be completed: 05/10/2019

1.The room located under dietary, where a large electrical trough with exposed internal wiring had the cover replaced. An inspection of all electric boxes will be completed to assure they are all properly covered and protected.

2.The electrical panel cover in basement corridor by the west pump room was re-secured. An inspection of all electric boxes will be completed to assure they are all properly covered and protected.

3. The junction box cover will be replaced with correct manufactures cover. An inspection of all electric boxes will be completed to assure they are all properly covered and protected.


Parkhouse will implement a Bi- monthly Tells monitoring system requirement that will generate a work order to inspect an area of the facility for exposed wires and unsecured junction boxes. Maintenance will correct the deficiency or have the Facilities Director and or Maintenance Supervisor call in the appropriate contractor for repairs. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tells monitoring system, which generates a log for tracking for QA purposes.

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: BUILDING 03 (WEST BUILDING) - Component: 03 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of power strips, affecting one of four levels.

Findings include:

1. Observation on March 12, 2019, at 10:25 am, revealed, in the 1st floor office across from the bank, a power strip was plugged into a power strip.

Interview at the exit conference with the Administrator, Regional Director of Facilities, and the Maintenance Director on March 12, 2019, at 2:50 pm, confirmed the unauthorized use of the electrical device.





 Plan of Correction - To be completed: 05/10/2019

The power strip found in the 1st floor office was removed.

Parkhouse has implemented a monthly Tels monitoring system requirement that will generate a work order to inspect an area of the facility for non-approved use of surge protectors and or power strips. Maintenance will correct the deficiency and if needed, have a work order entered into the Tels monitoring system to update the electrical access in the room so power strips and or surge protectors will not be needed. The system will automatically generate the work order on a monthly basis. Once the work is completed the Facilities Director or Maintenance Supervisor will input the completed work order into the Tells monitoring system, which generates a log for tracking and QA purposes.


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