Nursing Investigation Results -

Pennsylvania Department of Health
MORAVIAN VILLAGE OF BETHLEHEM
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MORAVIAN VILLAGE OF BETHLEHEM
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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MORAVIAN VILLAGE OF BETHLEHEM - 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 31, 2019, it was determined that Moravian Village of Bethlehem, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.





 Plan of Correction:


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 31, 2019, at 2:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes tracking the location of on-duty staff and patients.

Interview with the director of plant operations and administrator on January 31, 2019, at 2:00 p. m., confirmed the Emergency Preparedness Plan did not include the above element.





 Plan of Correction - To be completed: 03/18/2019

- Procedures for tracking the location of staff and residents during an emergency situation will be developed and sent to the Quality Assurance Committee for approval and inclusion in the Emergency Preparedness Manual. Staff will be educated on the procedures to track the location of staff and residents during an emergency.
- The policies in the Emergency Preparedness Manual will be reviewed by the Safety Officer or his designee at least annually and whenever a significant change to operations occurs. Policy additions and changes will be submitted to Quality Assurance Committee for approval.

- Completion date: March 18, 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, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 31, 2019, at 3:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes sharing plan information with residents' families or representatives.

Interview with the director of plant operations and administrator on January 31, 2019, at 3:00 p. m., confirmed the Emergency Preparedness Plan did not include the above element.





 Plan of Correction - To be completed: 03/18/2019

- The Communication Policy shall be updated to include the method and process for sharing information from the Emergency Preparedness Plan with residents and their representatives. The updated policy will be sent for approved to the Quality Assurance Committee for inclusion in the Emergency Preparedness Manual. Staff will be educated on the Communication Policy. Residents and their representatives will be made aware of appropriate information in the Emergency Preparedness Plan through the Facility's website and the Safety Officer.
- The policies in the Emergency Preparedness Manual will be reviewed by the Safety Officer or his designee at least annually and whenever a significant change to operations occurs. Policy additions and changes will be submitted to Quality Assurance Committee for approval.

- Completion date: March 18, 2019.

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


Facility ID# 15970201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 31, 2019, it was determined that Moravian Village of Bethlehem, 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 (000), unprotected, noncombustible building, with a basement, that 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 - Component: 01 - Tag: 0100

Based on interview, it was determined the facility failed to meet the required regulations set forth by Pennsylvania Act 48 for all areas with fossil fuel devices.

Findings include:

1. Interview with director of plant operations, on January 31, 2019, at 9:15 a.m., revealed the audible alarm signal for the carbon monoxide detectors (tied into the fire alarm system) does not have an audible alarm that clearly differentiates between the detection of carbon monoxide and the presence of smoke.

Interview with director of plant operations, on January 31, 2019, at 9:15 a.m., confirmed the carbon monoxide detector alarm signal shall be different from a signal for a fire alarm device.




 Plan of Correction - To be completed: 03/18/2019

- An audible alarm for the carbon monoxide detectors that is clearly distinguishable from the fire alarm system shall be installed. The Maintenance Supervisor shall monitor and test the alarms regularly throughout the year. Staff shall be educated on the different types of alarm sounds.
- The Director of Plant Operations shall review any change that are to be made to the Carbon Monoxide and Fire Alarm systems and will ensure the audible alarms for the systems can clearly be differentiated. Any changes shall be reported to the Quality Assurance Committee.

- Completion date: March 18, 2019.

NFPA 101 STANDARD Multiple Occupancies - Contiguous Non-Health:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Multiple Occupancies - Contiguous Non-Health Care Occupancies
Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.4.1, 19.1.3.4.1
Observations:
Name: MAIN - Component: 01 - Tag: 0132

Based on observation and interview, it was determined the facility failed to maintain the two hour fire separation, with a non-health care occupancy, on one of two building levels, with a fire separation located at a non-conforming building.

Findings include:

1. Observation on January 31, 2019, at 1:15 p.m., revealed the basement fire barrier separation with the Independent Living (kitchen) had the following deficiencies:
a. the hardware on the right side fire door lacked a label to indicate it was "fire exit hardware".
b. unsealed data wires above the doors.

Interview with director of plant operations, on January 31, 2019, at 1:15 p.m., confirmed the above fire barrier deficiencies.




 Plan of Correction - To be completed: 03/18/2019

- The hardware on the basement door separating Healthcare from Independent Living shall be replaced with hardware that is certified as fire exit hardware and labeled as such. A person knowledgeable of fire doors shall inspect all fire rated door hardware on an annual basis for appropriate labeling.
The data wires above the basement doors separating HealthCare from Independent Living shall be sealed with an appropriately rated smoke/fire sealant. The Maintenance Supervisor or his designee shall inspect the penetrations around the door for proper sealing.


- The Director of Plant Operations or designee shall instructions any staff or company to seal all penetration made during any construction or maintenance work that is made in the facility. All work shall be inspected after completion. The results from the door and penetration inspections will be reported quarterly to the Quality Assurance Committee.

- Completion date: March 18, 2019

NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

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

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

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

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

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of eight smoke compartments in this component.

Findings include:

1. Observation on January 31, 2019, between 7:30 a.m. and 3:30 p.m., revealed the following construction deficiencies:

a. second floor, structural steel columns located at the second floor level, were not protected where penetrating the suspended ceiling portion of the rated ceiling assembly.
b. second floor, structural steel columns, located within the exit access corridor wall systems, were not protected on all four sides.

Interview with director of plant operations, on January 31, 2019, at 3:30 p.m., confirmed the above construction deficiencies.






 Plan of Correction - To be completed: 03/18/2019

- The facility requests a Fire Safety Evaluation System, FSES, be conducted for the 2019 survey cycle year.

- The Maintenance Director or his designee will monitor building construction and renovations for compliance with the fire rating requirements for the facility. Changes will be reported to the Quality Assurance committee.

- Completion date: March 18, 2019.

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 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress, to be free of all obstructions to full use in case of emergency, at two of three building levels.

Findings include:

1. Observation on January 31, 2019, between 10:05 a.m. and 11:20 a.m., revealed the following exit obstructions:
a. (10:05 a.m.) second floor, north stair tower, near resident room 255, had a sign posted on the exit door, "this door is alarmed, do not use as an exit". This could be confusing to an individual who needs to utilize this designated exit.
b. (11:00 a.m.) first floor, Four Seasons memory unit, lacked a "not an exit" sign at memory garden (courtyard) doors.
c. (11:20 a.m.) first floor, north stair tower door to the outside (at the back of physical therapy department), is difficult to open.

Interview with director of plant operations, on January 31, 2019, at 11:20 a.m., confirmed the above means of egress deficiencies.







 Plan of Correction - To be completed: 03/18/2019

- The sign stating "Do Not Use" and posted near the second floor, north stair tower has been removed. The Maintenance Supervisor or designee shall inspect all exit doors annually for proper signage.
A "Not an Exit" sign shall be posted at the door to the Memory Garden in the Four Seasons Room. The Maintenance Supervisor or designee shall inspect all doors with exterior access quarterly for proper signage.
The door to the north stair tower on the first floor will be adjusted to ease its use of operation. All doors shall be inspected by the Maintenance Supervisor or designee annually for ease of use and latching.

- The Director of Plant Operations or his designee shall report the results of the door inspections to the Quality Assurance Committee annually or as changes are made.

- Completion date: March 18, 2019


NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings at two of five vertical shafts.

Findings include:

1. Observation on January 31, 2019, between 1:03 p.m. and 1:07 p.m., revealed the following stair towers had unsealed openings:
a. (1:03 p.m.) basement, stair tower at end of east storage, had unsealed penetrations and openings along the wall joints and corrugated decking.
b. (1:07 p.m.) basement, stair tower at elevators, had unsealed conduit.

Interview with director of plant operations, on January 31, 2019, at 1:07 p.m., confirmed the above unsealed penetrations and openings in the stair towers.





 Plan of Correction - To be completed: 03/18/2019

- The penetrations in the east stair tower in the basement area will be sealed with an appropriately rated smoke/fire sealant.
The penetrations in the center stair tower in the basement area will be sealed with an appropriately rated smoke/fire sealant.

- Stair towers will be inspected quarterly for penetrations by the maintenance staff. The Director of Plant Operations or his designee shall report the results of the inspections to the Quality Assurance Committee quarterly.

- Completion date: March 18, 2019

NFPA 101 STANDARD Sprinkler System - Maintenance 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.
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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the fire sprinkler system for one of one system.

Findings include:

1. Observation on January 31, 2019, between 1:25 p.m. and 1:35 p.m., revealed the following sprinkler deficiencies:
a. (1:25 p.m.) basement, fire sprinkler valve in the resident storage/paint room, lacked a label to indicate what type of valve it is.
b. (1:35 p.m.) facility lacked extra sprinkler heads for every type of head within the facility (sidewall type sprinklers, for example).

Interview with director of plant operations, on January 31, 2019, at 1:35 p.m., confirmed the above fire sprinkler deficiencies.





 Plan of Correction - To be completed: 03/18/2019

- The fire sprinkler valve in the storage/paint room will be labeled to indicate what type of valve it is.
Extra sprinkler heads for every type of sprinkler heads utilized in the facility will be obtained and placed in inventory.
A certified sprinkler inspection company will inspect all sprinkler heads, including spares, to verify proper labeling and sufficient replacement parts are on hand on a quarterly basis.

- The Director of Plant Operations or his designee shall report the results of the inspections to the Quality Assurance Committee on a quarterly basis.

- Completion date: March 18, 2019

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 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barriers at one of six smoke barriers.

Findings include:

1. Observation on January 31, 2019, at 11:10 a.m., revealed the first floor, 1-North smoke barrier wall, near soiled linen, had an unsealed data wire penetration.

Interview with director of plant operations, on January 31, 2019, at 11:10 a.m., confirmed the above unsealed penetration within the smoke barrier.





 Plan of Correction - To be completed: 03/18/2019

- The penetrations on the first floor, 1-north smoke barrier wall, near the soiled linen room will be sealed with an appropriately rated smoke/fire sealant. The Maintenance Supervisor or his designee will inspect any project area for penetrations after the cabling/wiring work has been done.

- The Director of Plant Operations or his designee shall report the results of the inspections quarterly to the Quality Assurance Committee.


- Completion date: March 18, 2019

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 - Component: 01 - Tag: 0914

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

Findings include:

1. Document review on January 31, 2019 at 8:45 a.m., revealed the facility lacked documentation that the patient bed electrical receptacles were tested annually to include:
a. physical integrity visual inspection.
b. verification of continuity of the grounding circuit.
c. conformation of correct polarity.
d. verification of retention force of the grounding blade, not less than four ounces.

Interview with director of plant operations, on January 31, 2019, at 8:45 a.m., confirmed the above electrical receptacle documentation was not available at the time of the survey.





 Plan of Correction - To be completed: 03/18/2019

- The electrical receptacles at the resident bed locations will be tested for physical integrity, continuity of grounding circuit, correct polarity and retention force of the grounding blade. The receptacles shall be tested by the Maintenance staff annually and after replacement or servicing.

- The Director of Plant Operations or his designee shall report the results of the inspections to the Quality Assurance Committee annually or as repairs and maintenance are done.

- Completion date: March 18, 2019

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN - Component: 01 - Tag: 0918

Based on observation, document review and interview, it was determined the facility failed to maintain regulations for one of one emergency generator.

Findings include:

1. Document review on January 31, 2019 at 8:30 a.m., revealed the facility lacked documentation that the generator battery voltage was checked weekly.

Interview with director of plant operations, on January 31, 2019, at 8:30 a.m., confirmed the battery voltage weekly inspection documentation was not available at the time of the survey.

2. Observation on January 31, 2019, at 1:30 p.m., revealed the basement, mechanical/emergency generator room cooling tower pipe, was leaking above the emergency generator at the time of the survey. This leak showered a large amount of water on the emergency generator, ceiling light fixture, receptacles, and other electrical equipment in this area. Facility shall verify the generator equipment and electrical components within this room were not damaged as a result of this water leak.

Interview with director of plant operations, on January 31, 2019, at 1:30 p.m., confirmed the above emergency generator and electrical components within the room were not damaged by the water leak.




 Plan of Correction - To be completed: 03/18/2019

- The battery voltage for the emergency generator will be tested weekly.
The leaking cooling tower pipe was repaired. No damage occurred to the emergency generator nor to the electrical components in the area. The Generator room will be inspected weekly for safety and general conditions.

- The results of the voltage testing and generator room safety inspection shall be reported by the Director of Plant Operations or his designee to the Quality Assurance Committee quarterly.

- Completion date: March 18, 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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical power and extension cords on two of three building levels.

Findings include:

1. Observation on January 31, 2019, between 10:00 a.m. and 1:20 p.m., revealed the following electrical cord deficiencies:
a. (10:00 a.m.) second floor, north corridor, between resident room 241 and smoke barrier, had an extension cord above the lay-in ceiling tile.
b. (10:10 a.m.) second floor, post acute care manager office, had a coffee maker plugged into a surge protector.
c. (10:15 a.m.) second floor, RNAC office, had a coffee maker, microwave oven and refrigerator plugged into a surge protector.
d. (10:20 a.m.) second floor, room 269, was utilizing an extension cord.
e. (1:20 p.m.) basement, women's break room, had a toaster oven and toaster plugged into a 3 X 1 electrical adapter.

Interview with director of plant operations, on January 31, 2019, at 1:20 p.m., confirmed the above electrical cord deficiencies.






 Plan of Correction - To be completed: 03/18/2019

- The extension cord lying above the lay-in ceiling on the second floor, north corridor near room 241 has been removed.
The coffee maker was unplugged from the surge protector in the second floor post-acute care manager office.
The coffee maker, microwave and refrigerator were unplugged from the surge protector in the second floor RNAC office.
The extension cord was removed from room 269.
The 3x1 electrical adaptor was removed from the women's break room.
The Maintenance staff shall inspect rooms for extension cords, surge protectors and electrical adaptors during the course of their audits and repair work.

- The Director of Plant Operations shall report the results of the electrical component audits quarterly to the Quality Assurance Committee.

- Completion date: March 18, 2019

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN - Component: 01 - Tag: 0923

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

Findings include:

1. Observation on January 31, 2019, at 1:00 p.m., revealed the basement, main oxygen storage room, had a door that could not be secured against unauthorized entry.

Interview with director of plant operations, on January 31, 2019, at 1:00 p.m., confirmed the above oxygen storage room door was not secured against unauthorized entry.





 Plan of Correction - To be completed: 03/18/2019

- The door accessing the main oxygen storage room will be secured by a lock.
Access will be limited to authorized personnel. Facility Services staff will inspect the main oxygen room on a daily basis to verify it is locked and secured.

- The results of the main oxygen room inspection will be reported to the Quality Assurance Committee by the Director of Plant Operations.

- Completion date: March 18, 2019


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