Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT EASTON, THE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT EASTON, THE
Inspection Results For:

There are  38 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.
GARDENS AT EASTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 29, 2019, it was determined that The Gardens at Easton, 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: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.
[(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, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 1:40 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes:
a. Persons at risk.
b. Types of services provided during an emergency.

Interview with the maintenance director on January 29, 2019, at 1:40 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.








 Plan of Correction - To be completed: 03/30/2019

1.Facility will revise EP plan to include identification of persons at risk, and types of services provided during an emergency.
2.Maintenance supervisor will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit revised manual annually to QA/PI for review/signatures.
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, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 1:45 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes subsistence needs for staff and patients including:
a. Safe storage of food, water, medical supplies and pharmaceuticals.
b. Sewage and waste disposal.

If the above is not able to be maintained throughout an emergency, an evacuation would have to occur at that time.

Interview with the maintenance director on January 29, 2019, at 1:45 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.






 Plan of Correction - To be completed: 03/30/2019

1.Facility will revise EP plan to include identification of subsistence needs for staff/patients, including A)safe storage of food, water, medical supplies, sewage/waste disposal.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
483.73(b)(2) REQUIREMENT Procedures for Tracking of Staff and Patients:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:]

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

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

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

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

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

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

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 1:50 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes tracking the location of on-duty staff and patients.

Interview with the maintenance director on January 29, 2019, at 1:50 p.m., confirmed the Emergency Preparedness Plan did not include the above element.







 Plan of Correction - To be completed: 04/19/2019

1.Facility will revise EP plan to include tracking location of on-duty staff/patients.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
483.73(b)(4) REQUIREMENT Policies/Procedures for Sheltering in Place: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:]

(4) A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility].

*[For Inpatient Hospices at 418.113(b):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.
Observations:
Name: - Component: -- - Tag: 0022

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 1:55 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes a plan for shelter in place.

Interview with the maintenance director on January 29, 2019, at 1:55 p.m., confirmed the Emergency Preparedness Plan did not include the above element.











 Plan of Correction - To be completed: 04/19/2019

1.Facility will revise EP plan to include a plan for shelter in place.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
483.73(c)(7) REQUIREMENT Information on Occupancy/Needs:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

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

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

*[For Inpatient Hospice at 418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 2:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes facility occupancy type information to the Authority Having Jurisdiction.

Interview with the maintenance director on January 29, 2019, at 2:00 p.m., confirmed the Emergency Preparedness Plan did not include the above element.










 Plan of Correction - To be completed: 03/30/2019

1.Facility will revise EP plan to include facility occupancy type information to DOH/Ombudsman/other appropriate jurisdictions.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

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

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 2:05 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes sharing plan information with residents' families or representatives.

Interview with the maintenance director on January 29, 2019, at 2:05 p.m., confirmed the Emergency Preparedness Plan did not include the above element.





 Plan of Correction - To be completed: 03/30/2019

1.Facility will revise EP plan to include sharing plan information with residents/responsible parties.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
483.73(d) REQUIREMENT EP Training and Testing: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.
(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, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 2:10 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes an annual emergency management training and testing for all staff.

Interview with the maintenance director on January 29, 2019, at 2:10 p.m., confirmed the Emergency Preparedness Plan did not include the above element.






 Plan of Correction - To be completed: 03/30/2019

1.Facility will revise EP plan to include specification of training/testing for all staff.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
483.73(d)(1) REQUIREMENT EP Training Program:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(1) Training program. The [facility, except CAHs, ASCs, PACE organizations, PRTFs, Hospices, and dialysis facilities] must do all of the following:

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

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

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

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

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

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

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

Observations:
Name: - Component: -- - Tag: 0037

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 29, 2019, at 2:10 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes an initial training on emergency management for individuals providing services (including volunteers).

Interview with the maintenance director on January 29, 2019, at 2:10 p.m., confirmed the Emergency Preparedness Plan did not include the above element.




 Plan of Correction - To be completed: 03/30/2019

1.The facility will revise EP plan to include initial training on EP for staff, volunteers, and individuals providing resident services.
2.Maintenance Director will update EP manual as regulations change.
3.Maintenance Director will review EP changes real time with NHA. NHA will submit EP manual annually to QA/PI for review/signatures.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 140602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2019, it was determined that The Gardens at Easton, 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 two story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain unobstructed means of egress in one of six smoke zones.

Findings include:

1. Observation on January 29, 2019, at 10:45 a.m., revealed the Arcade room had an exit sign above the door to the outside. This exit discharge to a public way was obstructed by a supply of plastic milk crates and a fence.

Exit interview with maintenance director on January 29, 2019, at 10:45 a.m., confirmed the above exit discharge was obstructed.







 Plan of Correction - To be completed: 01/30/2019

1.Arcade room exit blockage removed: milk crates disposed, fence dismantled.
2.Maintenance will conduct weekly rounds to assure no exit doors are blocked.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting x 1 month.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




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

Based on observation and interview, it was determined the facility failed to maintain stair towers at two of three exit stairs.

Findings include:

1. Observation on January 29, 2019, between 9:30 a.m. and 1:35 p.m., revealed the following stair tower deficiencies:
a. (9:30 a.m.), second floor, stair tower door, across from resident room 200, is damaged, cracked.
b. (10:56 a.m.), basement floor, stair tower door frame, lacked a label to indicate the fire rating, and the door lacked positive latching.
c. (10:57 a.m.), basement floor, stair tower door, north to mechanical room/laundry, was damaged near the latching hardware, and the door frame lacked a label to indicate the fire rating
d. (10:59 a.m.), basement floor, stair tower landing (near door to the outside), had an exam table and physical therapy equipment stored within the stair tower discharge.
e. (11:25 a.m.), second floor, stair tower door frame, across from resident room 215, lacked a label to indicate the fire rating.
f. (1:35 p.m.) , first floor, stair tower door, next to dining, was damaged, and lacked positive latching with the door hardware (door is only held closed with the magnetic lock).

Exit interview with maintenance director on January 29, 2019, at 1:35 p.m., confirmed the above stair tower deficiencies.








 Plan of Correction - To be completed: 03/30/2019

1.Facility will replace identified doors with approved smoke and fire doors, or recertify doors, via approved re-certification vendor, as follows:
A.Replace
B.Replace
C.Re-certify
D.Exam table and therapy equipment removed from stair tower discharge.1/30/19.
E.Re-certify
F.Replace
2.Maintenance Director will conduct monthly rounds to assure correct operation/integrity of smoke proof enclosures, and to assure no exit discharges are blocked.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting.
NFPA 101 STANDARD Horizontal 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.
Horizontal Exits
Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4.
18.2.2.5, 19.2.2.5




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0226

Based on observation and interview, it was determined the facility failed to maintain horizontal exits on one of three building levels.

Findings include:

1. Observation on January 29, 2019, at 10:30 a.m., revealed the basement, horizontal exit fire barrier door frame, from Annex building to Skilled building at classroom, lacked a label to indicate the fire rating.

Exit interview with maintenance director on January 29, 2019, at 10:30 a.m., confirmed the above horizontal exit door frame deficiency.






 Plan of Correction - To be completed: 03/30/2019

1.Facility will re-certify identified doors via approved re-certification vendor.
2.Maintenance Director will conduct monthly rounds to assure all doors have correct labels indicating fire rating.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting x 1 month.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical enclosures affecting two of two floors in this component.

Findings include:

1. Observation on January 29, 2019, between 9:25 a.m. and 1:37 p.m., revealed the vertical shaft enclosures lacked the required one-hour fire resistance rating due to a single layer of five eighths of an inch thick gypsum board, affixed to internal metal support studding.

Exit interview with the maintenance director on January 29, 2019, at 1:37 p.m., confirmed the vertical enclosure deficiency.







 Plan of Correction - To be completed: 03/30/2019

The facility requests to use FSES reviewed 29 January 2019.
NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

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

Based on observation and interview, it was determined the facility failed to maintain hazardous areas on two of three building levels.

Findings include:

1. Observation on January 29, 2019, between 10:50 a.m. and 1:15 p.m., revealed the following hazardous area deficiencies:
a. (10:50 a.m.), basement, soiled utility room door, across from the Arcade room, was damaged, exposing the core material.
b. (1:15 p.m.), first floor, tub room, across from resident room 107, was used for storage of soiled linen bins.

Exit interview with maintenance director on January 29, 2019, at 1:15 p.m., confirmed the above hazardous area deficiencies.






 Plan of Correction - To be completed: 03/30/2019

1A.Facility will replace identified skilled utility door with approved smoke/fire door.
1B.Soiled linen carts removed from tub room. 1/30/19.
2.Maintenance Director will conduct monthly rounds to assure correct operation/integrity of smoke proof enclosures; and to assure soiled linen carts are not in tub room.
3.Maintenance Director will report results of rounds to month QA/PI meeting x 1 month.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain fire sprinkler systems for one of four quarters within the last year.

Findings include:

1. Document review on January 29, 2019, at 8:45 a.m., revealed the facility lacked documentation that a quarterly fire sprinkler inspection was performed during the second quarter (April, May or June) of 2018.

Exit interview with maintenance director on January 29, 2019, at 8:45 a.m., confirmed the above quarterly fire sprinkler test documentation was not available at the time of the survey.




 Plan of Correction - To be completed: 03/30/2019

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

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

Based on observation and interview, it was determined the facility failed to maintain corridor doors at two of over fifty corridor doors.

Findings include:

1. Observation on January 29, 2019, between 11:20 a.m., and 1:30 p.m., revealed the following corridor doors lacked positive latching:
a. (11:20 a.m.), second floor, resident room 211.
b. (1:30 p.m.) first floor, resident room 126 (wheelchair placed in path of door swing).

Exit interview with maintenance director on January 29, 2019, at 1:30 p.m., confirmed the above doors lacked positive latching.





 Plan of Correction - To be completed: 02/15/2019

1A.Room 211 door positive latching fixed.2/15/19.
1B.Wheelchair moved from resident room 126 door swing path. 1/30/19.
2.Maintenance Director will conduct monthly rounds to assure correct operation/integrity of smoke proof enclosures; and to assure no objects block door swing path.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting x 1 month.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain fire/smoke doors at four of over twenty-five doors.

Findings include:

1. Document review on January 29, 2019, at 8:15 a.m., revealed the last annual fire/smoke door inspection, revealed four deficient doors that did not meet regulations. Facility lacked documentation that these deficient doors have been corrected.

Exit interview with maintenance director on January 29, 2019, at 8:15 a.m., confirmed the facility lacked documentation that the deficient doors had been corrected.






 Plan of Correction - To be completed: 03/30/2019

Repeat Citation 0225
1.Faciilty will replace four identified doors with approved smoke and fire doors.
2.Maintenance Director will conduct monthly rounds to assure operation/integrity of smoke proof enclosures.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting.
NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain electrical receptacles at resident bed locations, on two of three building levels.

Findings include:

1. Document review on January 29, 2019, at 8:30 a.m., revealed the facility lacked documentation that an annual receptacle test was done at all patient bed locations (polarity, tension, and overall condition).

Exit interview with maintenance director on January 29, 2019, at 8:30 a.m., confirmed the electrical receptacle testing documentation was not available at the time of the survey.





 Plan of Correction - To be completed: 03/30/2019

1.Maintenance Director will obtain receptacle test tool, and will document all bed locations are tested annually for polarity, tension, and overall condition.
2.Maintenance Director will conduct annual receptacle testing, and maintain documentation.
3.Maintenance Director will report results of annual receptacle testing at monthly QA/PI meeting.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical power cords at three of over 100 rooms.

Findings include:

1. Observation on January 29, 2019, between 11:00 a.m. and 11:30 a.m., revealed the following electrical power cord deficiencies:
a. (11:00 a.m.), basement, Central Supply office, had two surge protectors permanently affixed to the wall.
b. (11:15 a.m.), basement, Dietary office had a surge protector plugged into another surge protector. This surge protector also is suspended above the floor by the cords plugged into it.
c. (11:30 a.m.), second floor, Medical Records office, had a coffee maker, portable heater, and an extension cord plugged into a surge protector.

Exit interview with maintenance director on January 29, 2019, at 11:30 a.m., confirmed the above power cord deficiencies.





 Plan of Correction - To be completed: 02/15/2019

1.Maintenance Director will remove or modify incorrectly installed/used, surge protectors as follows:
A.Surge protectors removed from wall. 2/15/2019.
B.Surge protectors reduced to 1 unit. 1/29/2019.
C.Heater,coffee maker,extension cord, removed from surge protector. 1/29/2019.
2.Maintenance Director will conduct monthly rounds to assure surge protector are properly used.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting x 1 month.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID# 140602
Component 02
Annex

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2019, it was determined that The Gardens at Easton, 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 two story, Type II (222), fire resistive building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain unobstructed means of egress in two of three smoke zones.

Findings include:

1. Observation on January 29, 2019, at 10:00 a.m., revealed the lower annex, breezeway exit (close to resident smoking area), had a wheel chair stored in the path of egress.

Exit interview with maintenance director on January 29, 2019, at 10:00 a.m., confirmed the above exit discharge was obstructed.




 Plan of Correction - To be completed: 01/30/2019

1.Resident wheelchair removed from path of egress. Resident advised of correct storage location.
2.Activities smoking attendants will monitor area to assure residents use correct wheel chair storage location.
3.Activities Director will report results of smoke area monitoring to monthly QA/PI meeting.
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 02 - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stair towers at one of two exit stairs.

Findings include:

1. Observation on January 29, 2019, at 10:20 a.m., revealed the upper annex, stair tower solarium, north door, had holes in the door that were not sealed with the proper material.

Exit interview with maintenance director on January 29, 2019, at 10:20 a.m., confirmed the above stair tower deficiency.




 Plan of Correction - To be completed: 02/15/2019

1.Door sealed with proper metal material.
2.Maintenance Director will do monthly rounds to assure all door penetrations properly sealed; and will submit doors requiring replacement to NHA.
3.Maintenance Director will review any found door penetrations with NHA as needed.
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 - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area storage regulations at one of two building levels.

Findings include:

1. Observation on January 29, 2019, at 10:10 a.m., revealed the upper solarium, activity storage room door, lacked positive latching with the self-closure, due to clothing items hanging on the back of the door.

Exit interview with maintenance director on January 29, 2019, at 10:10 a.m., confirmed the above storage room door lacked positive latching.




 Plan of Correction - To be completed: 01/29/2019

1.Coat rack removed from back of activity storage door.
2.Activities staff advised not to block self closing door. Activities Director will monitor storage room for compliance.
3.Activities Director will report results of storage room monitoring to monthly QA/PI x 1 month.
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: BUILDING 02 - Component: 02 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain fire sprinkler systems for one of four quarters within the last year.

Findings include:

1. Document review on January 29, 2019, at 8:45 a.m., revealed the facility lacked documentation that a quarterly fire sprinkler inspection was performed during the second quarter (April, May or June) of 2018.

Exit interview with maintenance director on January 29, 2019, at 8:45 a.m., confirmed the above quarterly fire sprinkler test documentation was not available at the time of the survey.





 Plan of Correction - To be completed: 03/30/2019

Repeat 0353 citation.
1.Facility conducted 4 total fire sprinkler inspections: April-May-July-December. The Maintenance Director will add quarterly due dates to TELS for 3 required inspections.
2.Maintenance Director will monitor TELS alerts for quarterly fire sprinkler inspections.
3.Maintenance Director will report results of TELS compliance for quarterly fire sprinkler inspections to monthly QA/PI meeting.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers at one of over five extinguisher locations.

Findings include:

1. Observation on January 29, 2019, at 10:03 a.m., revealed the fire extinguisher located at the outside resident designated smoking area had a low charge on the gauge.

Exit interview with maintenance director on January 29, 2019, at 10:03 a.m., confirmed the above fire extinguisher needed recharged.






 Plan of Correction - To be completed: 01/30/2019

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

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations at one of three designated smoking areas.

Findings include:

1. Observation on January 29, 2019, at 10:05 a.m., revealed the outside resident designated smoking area lacked a metal container, with a self-closing cover device into which ashtrays can be emptied, available to all areas where smoking is permitted.

Exit interview with maintenance director on January 29, 2019, at 10:05 a.m., confirmed the above smoking area lacked a self-closing metal receptacle for cigarette butts.




 Plan of Correction - To be completed: 03/30/2019

1.Maintenance Director will purchase metal, self-closing, red, smoking receptacles(2)for smoking areas.
2.Housekeeping Director will monitor smoking receptacles weekly for proper use/emptying.
3.Housekeeping Director will report results of monitoring to monthly QA/PI meeting.
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 02 - Component: 02 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain fire/smoke doors at four of over twenty-five doors.

Findings include:

1. Document review on January 29, 2019, at 8:15 a.m., revealed the last annual fire/smoke door inspection revealed four deficient doors that did not meet regulations. Facility lacked documentation that these deficient doors have been corrected.

Exit interview with maintenance director on January 29, 2019, at 8:15 a.m., confirmed the facility lacked documentation that the deficient doors had been corrected.





 Plan of Correction - To be completed: 03/30/2019

Repeat 0225/0761 citations.
1.Faciilty will replace four identified doors with approved smoke and fire doors.
2.Maintenance Director will conduct monthly rounds to assure operation/integrity of smoke proof enclosures.
3.Maintenance Director will report results of rounds to monthly QA/PI meeting.

NFPA 101 STANDARD Electrical Systems - 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.
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: BUILDING 02 - Component: 02 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain electrical receptacles at resident bed locations, on two of three building levels.

Findings include:

1. Document review on January 29, 2019, at 8:30 a.m., revealed the facility lacked documentation that an annual receptacle test was done at all patient bed locations (polarity, tension, and overall condition).

Exit interview with maintenance director on January 29, 2019, at 8:30 a.m., confirmed the electrical receptacle testing documentation was not available at the time of the survey.




 Plan of Correction - To be completed: 03/30/2019

Repeat 0914 citation.
1.Maintenance Director will obtain receptacle test tool, and will document all bed locations are tested annually for polarity, tension, and overall condition.
2.Maintenance Director will conduct annual receptacle testing, and maintain documentation.
3.Maintenance Director will report results of annual receptacle testing at monthly QA/PI meeting.

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 - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain compressed gas cylinder storage regulations at one of two building levels.

Findings include:

1. Observation on January 29, 2019, at 10:07 a.m., revealed the upper solarium, activity storage room, had an unsecured helium cylinder.

Exit interview with maintenance director on January 29, 2019, at 10:07 a.m., confirmed the above area had an unsecured helium cylinder.




 Plan of Correction - To be completed: 03/30/2019

1.Correct helium tank storage holder ordered.
2.Activities Director will monitor helium tank for correct storage.
3.Activities Director will report results of helium tank storage monitoring to QA/PI meeting x 1 month.

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