Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES
Building Inspection Results

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WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES
Inspection Results For:

There are  34 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.
WILLOWBROOKE COURT AT SOUTHAMPTON ESTATES - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on February 20, 2019, it was determined that Willowbrooke Court At Southampton Estates was not in compliance with the requirements of 42 CFR 483.73.


 Plan of Correction:


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
Emergency Plan policies and procedures that addressed sewage and waste disposal during an emergency, affecting the entire facility.

Findings include

1. Document review on February 20, 2019, at 8:00 am, revealed the the facility could not produce Emergency Plan policies and procedures that addressed sewage and waste disposal during an emergency

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/30/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law.

NHA or designee will incorporate procedures regarding sewage and waste disposal to the emergency plan by April 30, 2019.

Education of community staff will be completed by NHA or designee by April 30, 2019.

483.73(b)(3) REQUIREMENT Policies for Evac. and Primary/Alt. Comm.: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:]

Safe evacuation from the [facility], 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 RNHCs at 403.748(b)(3) and ASCs at 416.54(b)(2):]
Safe evacuation from the [RNHCI or ASC] which includes the following:
(i) Consideration of care needs of evacuees.
(ii) Staff responsibilities.
(iii) Transportation.
(iv) Identification of evacuation location(s).
(v) Primary and alternate means of communication with external sources of assistance.

* [For CORFs at 485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at 485.727(b)(1), and ESRD Facilities at 494.62(b)(2):]
Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients.

* [For RHCs/FQHCs at 491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0020

Based on document review and interview, it was determined the facility's emergency preparedness communication plan failed to include a primary and alternate form of communication with external sources of assistance, affecting the entire facility.

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the the facility failed to include a primary and alternate form of communicating with external sources of assistance.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 04/30/2019

The Emergency plan does include procedures on primary and alternate forms of communication. The documentation was available at the time of the survey for review.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 30, 2019.

483.73(b)(5) REQUIREMENT Policies/Procedures for Medical Documentation: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:]

(5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at 403.748(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[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.
Observations:
Name: - Component: -- - Tag: 0023

Based on document review and interview, it was determined the facility failed to develop and maintain an Emergency Preparedness plan that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility.

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the facility did not have an Emergency Plan that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/30/2019

The Emergency plan does include system information on the electric health record and its portability in an emergency. The documentation was available at the time of the survey for review.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 30, 2019.

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 ensure policies and procedures were in place addressing 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, affecting the entire facility.

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the Facilities Emergency Preparedness Plan did not have policy and procedures addressing 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.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/30/2019

The Emergency plan does include procedures on the use of volunteers, state and other healthcare professionals. The documentation was available at the time of the survey for review.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 30, 2019.

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

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

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

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

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the Emergency Preparedness plan did not include Policies and Procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver during a declared emergency.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 04/30/2019

NHA or designee will incorporate procedures regarding the 1135 waiver into the emergency plan by April 30, 2019.

Education of community staff will be completed by NHA or designee by April 30, 2019.

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's emergency preparedness communication plan failed to include all of the required names and contact information, affecting the entire facility.

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the facility's emergency preparedness communication plan did not include the names and contact information for the following:

a. Resident's physicians.
b. Volunteers.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 04/30/2019

NHA or designee will add physician and volunteer contact information into the emergency plan by April 30, 2019.

Education of community staff will be completed by NHA or designee by April 30, 2019.

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's emergency preparedness communication plan failed to include a primary and alternate form of communication, affecting the entire facility.

Findings include

1. Document review on February 20, 2019, at 8:00 am, revealed the the facility failed to include a primary and alternate means of communicating with the following:

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

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/30/2019

The Emergency plan does include primary and alternative means of communication with staff and municipalities. The documentation was available at the time of the survey for review.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 30, 2019

483.73(c)(4)-(6) REQUIREMENT Methods for Sharing 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:

(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.

(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under 484.102(c), CORFs under 485.68(c), and RHCs/FQHCs under 491.12(c).]

(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).

*[For RNHCIs at 403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.

*[For RHCs/FQHCs at 491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Name: - Component: -- - Tag: 0033

Based on document review and interview, it was determined the facility's emergency preparedness communication plan failed to include a method for sharing information and medical documentation for patients under the facility's care, with other health care providers to maintain the continuity of care, affecting the entire facility.

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the facility's emergency preparedness communication plan lacked a method for sharing information and medical documentation for patients under the facility's care, with other health care providers to maintain the continuity of care.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/30/2019

The Emergency plan does include procedures sharing medical information and other necessary resident information with healthcare providers. The documentation was available at the time of the survey for review.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 30, 2019.

483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

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

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives, affecting the entire facility.

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the facility lacked a written Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 04/30/2019

The Emergency plan does include communication procedures with residents' families and responsible parties. The documentation was available at the time of the survey for review.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.
Education of community staff will be completed by NHA of designee on the table of contents by April 30, 2019.

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 documentation review and interview, it was determined the facility failed to develop
an emergency preparedness testing and training program that is based on the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

Document review on February 20, 2019 at 8:00 am, revealed the facility failed to develop an emergency preparedness testing and training program.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 04/21/2019

The Emergency plan does include procedures training and staff education. Table top and full drill exercises completed in the last 12 months are included with the emergency plan materials and were available for review at the time of the survey.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 21, 2019.

483.73(d)(1) REQUIREMENT EP Training Program: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.
(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 documentation review and interview, it was determined the facility failed to maintain a training program that is based on the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

Document review on February 20, 2019 at 8:00 am, revealed the facility failed to perform training to the emergency preparedness plan that included the following:

a. 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.
b. Provide emergency preparedness training at least annually.
c. Maintain documentation of the training.
d. Demonstrate staff knowledge of emergency procedures.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 04/21/2019

The Emergency plan does include procedures training and staff education. Table top and full drill exercises completed in the last 12 months are included with the emergency plan materials and were available for review at the time of the survey.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 21, 2019.

483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

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

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

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

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

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the facility could not provide documentation that an annual full scale exercise and an additional exercise was performed within the previous 12 months to test the emergency preparedness plan.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 04/21/2019

The Emergency plan does include procedures training and staff education. Table top and full drill exercises completed in the last 12 months are included with the emergency plan materials and were available for review at the time of the survey.

A table of contents will be developed to assist the future surveyor in locating the information in the emergency plan.

Education of community staff will be completed by NHA of designee on the table of contents by April 21, 2019.

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

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

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

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

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

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

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

Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the facility's Emergency Preparedness plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event the primary fuel supplier is unavailable during an emergency.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/21/2019

NHA or designee will add information regarding the secondary fuel supplier into the emergency plan by April 30, 2019.

Education of community staff will be completed by NHA or designee by April 21, 2019.

Initial comments:Name: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0000


Facility ID# 151302
Building 01
Willowbrooke Court, Special Care Unit, Oakbridge

Based on a Medicare/Medicaid Recertification Survey completed on February 20, 2019, it was determined that Willowbrooke Court At Southampton Estates was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (200), unprotected ordinary construction, with a lower level and partial 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 BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to install 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. Observation made on February 20, 2019, at 11:58 am, revealed the facility failed to install a carbon monoxide alarm for the gas fired boilers in the basement boiler room that serves the skilled nursing unit.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed a carbon monoxide alarm was not installed.



 Plan of Correction - To be completed: 03/22/2019

The carbon monoxide alarm was in place at the time of inspection, a label will be added to the alarm to indicate it is a carbon monoxide detector.

Monitoring of the carbon monoxide alarm is completed by an outside vendor bi-annually. Documentation is maintained with Plant Operations Director or designee.

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

Based on observation and interview, it was determined the facility failed to ensure egress doors with delayed-egress locking systems had required indicating signage displayed on the doors, affecting 1 of 2 levels within the facility.
Findings include:

1. Observations made on February 20, 2019, between 10:50 am and 11:48 am, revealed egress doors with delayed-egress locking systems installed that lacked required signage in the following locations that states:

"PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS "

a. 10:50 am, 1st floor, ILU-WBC double doors.
b. 11:45 am, 1st floor, inside the vestibule, the sunshine garden double doors that lead to the parking lot.
c. 11:48 am, 1st floor, double doors that lead from the sunshine garden center area to the patio.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the doors lacked the delayed egress signage in the above named locations.




 Plan of Correction - To be completed: 04/21/2019

Director of Plant Operations or designee will install appropriate signage on the identified doors by March 22, 2019.

Other doors, with delayed egress will be reviewed for appropriate signage.
Education will be completed with the maintenance team by the Director of Plant Operations or designee on the importance of appropriate signage on the delayed egress doors by April 21, 2019.

Preventative Maintenance program will be put in place to review the signage bi-annually on the door with delayed egress. Documentation will be maintained by Plant Operations Director. NHA or designee will complete random audits to ensure compliance and reported quarterly QAPI.

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 BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of hazardous storage rooms, affecting 1 of 2 levels within the facility.

Findings include:

1. Observation made on February 20, 2019, at 11:55 am, revealed inside the basement large storage room, there were two unsealed penetrations around armor conduits in the rated wall, above the door, above the ceiling.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the unsealed penetrations.




 Plan of Correction - To be completed: 04/21/2019

Director of Plant Operations or designee will address the identified penetration with the C-AJ-2075C stop penetrations system by April 21, 2019.
Director of Plant Operations or designee will inspect fire walls for areas of unsealed penetrations.

Contractors and other vendors will continue to be educated by Plant Operations Director or designee on the importance of ensuring any penetrations caused during work are sealed per regulations.

A preventative maintenance program is currently in place to review fire walls for unsealed penetration. This program will continue, and results will be reported to QAPI quarterly.

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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors, affecting 2 of 5 smoke zones within the facility.

Findings include:

1. Observation made on February 20, 2019, at 10:59 am, 1st floor, revealed inside the Chapel of Solace room, there was a large gap around a ceiling mounted smoke detector.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed there was a gap around a smoke detector.

2. Observations made on February 20, 2019, between 11:32 am and 11:37 am, revealed smoke detectors that were dislodged and hanging from the ceiling assembly in the following locations:

a. 11:32 am, 1st floor, inside the mud room that is located across from the sprinkler riser room.
b. 11:37 am, 1st floor, inside resident room # 123.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the dislodged smoke detectors in the above named locations.



 Plan of Correction - To be completed: 04/21/2019

The smoke detector was remount properly which closed the gap. This was completed by March 20, 2019.

The identified dislodged smoke detectors will be secured or replaced by March 22, 2019.

A review of the smoke detectors will be completed by March 31, 2019 to confirm smoke detectors are in compliance with this requirement.

Education will be completed by the Director of Plant Operations or designee with the maintenance staff regarding this requirement smoke detectors by April 21, 2019.

A preventative maintenance program will be put into place to visually inspect for proper placement of smoke detectors quarterly. An outside vendor is contracted to complete testing of smoke detectors semi-annually. Results will be reported to QAPI quarterly.

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

Based on document review and interview, it was determined the facility failed to ensure the automatic sprinkler system was inspected and maintained, affecting the entire facility.
Findings include:

1. Document review on February 20, 2019, at 8:00 am, revealed the the facility could not produce documentation that a sprinkler system obstruction inspection had been performed within the previous 5 years.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the documentation was not available.

2. Observation made on February 20, 2019, at 11:28 am, 1st floor, revealed two sprinklers with debris on them inside the Beauty Shop.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the sprinklers had debris on them.

3. Observation made on February 20, 2019, at 11:40 am, 1st floor, revealed a sprinkler was missing an escutcheon inside the SSG Spa Room.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the sprinkler was missing an escutcheon.



 Plan of Correction - To be completed: 04/15/2019

The other identified sprinkler head have been cleaned and are free of debris, March 20, 2019.

The identified escutcheon plates have been installed, March 20, 2019.

A sprinkler system obstruction inspection will be completed by April 15, 2019.

The sprinkler head will be visually inspected for debris and presence of escutcheon plates will be completed by March 25, 2019.

A Preventative Maintenance program has been established to ensure the presence of escutcheon plates, and that sprinkler heads are free of debris. Education will be completed by the Director of Plant
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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were inspected, affecting one of two levels within the facility.

Findings include:

Observations made on February 20, 2019, between 10:40 am and 11:41 am, revealed portable fire extinguishers with annual inspection tags dated 2017 in the following locations:

a. 10:40 am, 1st floor, inside the generator room.
b. 10:45 am. 1st floor, inside the dry goods storage room.
c. 11:41 am, 1st floor, inside the SSG Spa Room.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the portable fire extinguishers with expired inspection tags in the above named locations.



 Plan of Correction - To be completed: 03/31/2019

The identified annual inspection tags will be replaced by March 22, 2019.

The monthly fire extinguisher report has been updated to include the date of inspection tag and proper placement. Fire Extinguisher reports are reported to QAPI by the Security supervisor or designee.

A whole house audit of the fire extinguisher tags will be completed by March 31, 2019.

Plant Operations Director or designee will provide education with the security team responsible for the fire extinguisher rounds will be completed by March 31, 2019.

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

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

Based on observation and interview, it was determined the facility failed to ensure that corridor doors were free of gaps greater than one half of an inch which would not resist the passage of smoke, affecting 1 of 5 smoke zones within the facility.

Findings include:

1. Observation made on February 20, 2019, at 11:20 am, 1st floor, revealed there was a gap in the door to resident room # 8.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the door had a gap.




 Plan of Correction - To be completed: 04/15/2019

The identified door gap will be addressed by adding silicone, fire and smoke seal to reduce gap and passage of smoke.

Resident room doors are reviewed for gapping as part of the annual fire door inspection completed by an outside vendor.

Results of the inspection will be reported to QAPI upon competition by the Director of Plant Operations or designee.

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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of smoke barrier walls, affecting 2 of 5 smoke zones within the facility.

Findings include:

1. Observation made on February 20, 2019, at 11:05 am, 1st floor, revealed above the smoke barrier double doors near resident room # 21, above the ceiling, there was an unsealed penetration around around two electrical wires penetrating the smoke barrier wall.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the unsealed penetrations.



 Plan of Correction - To be completed: 04/21/2019

Director of Plant Operations or designee will address the identified penetration with the W-L-3423 stop penetration system by April 21, 2019.
Director of Plant Operations or designee will inspect fire walls for areas of unsealed penetrations.

Contractors and other vendors will continue to be educated by Plant Operations Director or designee on the importance of ensuring any penetrations caused during work are sealed per regulations.

A preventative maintenance program is currently in place to review fire walls for unsealed penetration. This program will continue, and results will be reported to QAPI quarterly.

NFPA 101 STANDARD HVAC - Any Heating Device:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0522

Based on observation and interview, it was determined the facility failed to maintain that heating units were free of combustible materials, affecting 1 of 5 smoke zones within the facility.

Findings include:

1. Observation made on February 20, 2019, at 11:25 am, 1st floor, revealed there were papers placed on a heater unit inside resident room # 2.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed there were papers resting on the heater unit.



 Plan of Correction - To be completed: 03/31/2019

Papers were removed from the heater at the time of the survey.

Resident has been educated on the importance of not placing anything on the heater.

Residents and staff will be educated by NHA or designee meeting on the importance of keeping heaters clear.

Weekly rounds will be completed by NHA or designee during the month's heaters circulators are in use. Results of the rounds will be reported to QAPI.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0916


Based on observation and interview, it was determined the facility failed to maintain generator annunciator panels, affecting the entire facility.

Findings include:

1. Observation made on February 20, 2019, at 11:12 am, revealed in the 1st floor corridor next to the Care Base Office, the generator remote annunciator panel's generator status lamps failed to function when the lamp test button was depressed.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the status lamps failed to function when tested.




 Plan of Correction - To be completed: 04/21/2019

The generator annunciator panel light will be evaluated for proper function by the community vendor and repaired by April 21, 2019.

A preventative maintenance program will be put in place to check the function of the annunciator panel monthly. Results of the testing will be kept with the generator testing.

Maintenance team member will be educated on the proper function of the annunciator panel by April 30, 2019.

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: MAIN BLDG 01(WILLOWBROOKE COURT, SPECIAL CARE) - Component: 01 - Tag: 0920


Based on observation and interview, it was determined the facility failed to ensure the improper use of powerstrips was prohibited, affecting 1 of 5 smoke zones within the facility.

Findings include:

1. Observation made on February 20, 2019, between 10:55 am and 10:57 am, revealed the improper use of powerstrips in the following locations:

a. 10:55 am, a microwave oven was plugged into a powerstrip inside the Director of Rehabilitation Office.
b. 10:57 am, 1st floor conference room, a microwave oven and a coffee maker were plugged into the same powerstrip.

Interview at the exit conference with the Maintenance Director and the Administrator's Assistant on February 20, 2019, at 12:00 pm, confirmed the improper use of powerstrips in the above named locations.




 Plan of Correction - To be completed: 04/21/2019

The microwave and coffee maker have been relocated in the Conference room to use a dedicated outlets.

The microwave has been relocated within the Director of Rehab's office to use a dedicated outlet.

The power strips have been removed from
these locations.

NHA or designee will complete rounds to ensure compliance with this requirement by March 25, 2019.

NHA or designee will provide education to community staff on the proper use of power strips and the importance of plugging equipment directly into a wall outlet by April 21, 2019.
Environmental rounds will be completed monthly and results reported to QAPI quarterly.


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