Pennsylvania Department of Health
PATRIOT, A CHOICE COMMUNITY THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PATRIOT, A CHOICE COMMUNITY THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Emergency Preparedness Survey completed on March 12, 2024, it was determined that The Patriot, A Choice Community, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD 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.

§482.15(e) Condition for Participation:
(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), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] 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), §485.542(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), §485.542(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),§485.542(e)(2)
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), REHs at §485.542(g), and 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 documentation review and interview, it was determined the facility failed to maintain the emergency generator testing and maintenance requirements in two instances affecting the entire facility.

Findings include:

1. Review of documentation on March 12, 2024, revealed the following emergency generator testing deficiencies:

a) 12:30 p.m., the facility lacked documentation for the monthly test/function of the transfer switch for January and February 2024;
b) 12:32 p.m., the facility failed to perform the required annual fuel quality testing in the past twelve months. The most recent fuel quality testing was performed on February 21, 2023.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the above-listed EP plan deficiencies.

Plan of Correction - To be completed: 04/16/2024

1a. Education was provided to Maintenance Director and technician that the seconds of initiation of the transfer switch needs to be documented when performing the monthly test. The review of the transfer switch testing will be completed monthly by the Maintenance Director or designee and the results brought to QAPI Committee for review.

1b. The annual fuel testing was completed on March 15, 2024. The Maintenance Director will ensure the fuel testing will be completed yearly.

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

Facility ID# 167902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 12, 2024, it was determined that The Patriot, A Choice Community was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (111), protected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

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 BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one instance, affecting three of fifteen smoke compartments.

Findings include:

1. Observation on March 12, 2024, at 9:00 a.m., revealed an unsealed fire alarm wire passing through a conduit in the elevator shaft wall, above the ceiling at the three east elevator doors, on the third-floor.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed vertical opening enclosure deficiency.

Plan of Correction - To be completed: 04/16/2024

1. The wire passing through a conduit in the elevator shaft was sealed with an approved fire rated material. The Director of Maintenance will ensure that vendors seal penetrations with approved fire rated materials when new wiring is added.

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on observation and interview the facility failed to install and maintain gas-fired cooking equipment in the kitchen in two instances, affecting one of fifteen smoke compartments. In accordance with NFPA 96

Findings include:

1. Observation on March 12, 2024, at 10:22 a.m., revealed the wheeled gas-fired oven/cook-top and the wheeled gas-fired convection oven located on the cooking line in the kitchen were not tethered in a way so they could not become detached from the gas supply line connection when moved for cleaning.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed gas-fired cooking equipment deficiency.

Plan of Correction - To be completed: 04/16/2024

1. The wheeled gas fired convection oven and wheeled gas fired oven/cook top have been tethered to the wall.

NFPA 101 STANDARD Sprinkler System - Supervisory Signals:

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 - Supervisory Signals
Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired.
9.7.2.1, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0352

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 72...14.4.5. Number 15 L (1)

Findings include:

1. Review of documentation on March 12, 2024, at 12:30 p.m., revealed the facility failed to perform the required semi-annual inspection of the automatic sprinkler system, valve supervisory switches/tamper switch (semi-annual) 14.4.5, initiating devices (1).

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed automatic sprinkler system testing deficiency.

Plan of Correction - To be completed: 04/16/2024

The semi-annual sprinkler test has been scheduled for March 28, 2024.

Education has been provided to the Maintenance Director and technician that they need to complete the required testing semi-annually and maintain the inspection results in their documentation.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in five instances, affecting four of fifteen smoke compartments.

Findings include:

1. Observation on March 12, 2024, revealed the following automatic sprinkler system deficiencies:

a) 8:57 a.m., inspection above the ceiling at the smoke barrier doors by resident room 349 revealed wires laying on top of the sprinkler pipe;
b) 9:17 a.m., inspection above the ceiling at stair tower number three on the third floor revealed an MC cable laying on top of the sprinkler pipe;
c) 9:25 a.m., inspection above the ceiling at stair tower number one on the third-floor revealed wires taped to the sprinkler pipe;
d) 10:16 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were broken ceiling tiles in the first-floor electrical room in the south wing;
e) 10:55 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There was a large, unsealed wire penetration above the security camera monitor in the admin-office storage room.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/16/2024

1 a-c The wires and cable resting on the sprinkler pipe have been separated and the electrical tape removed from the pipe.

d. The broken ceiling tiles in the first floor electrical room have been replaced.
The Maintenance Director will audit for broken tiles and report results to the QAPI committee.

e. The wire penetrations above the security camera outside the HR office have been sealed with a fire rated foam.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 BUILDING 01 - Component: 01 - Tag: 0355

Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguisher inspections in two instances, affecting the entire facility. in accordance with NFPA 10, 7.1.2.1

Findings include:

1. Review of documentation on March 12, 2024, at 12:35 p.m., revealed the following portable fire extinguisher inspection deficiencies:

a) the annual fire extinguisher inspection report lacked a signature of the individual who performed the inspection;
b) the facility lacked documentation indicating that the individual who conducted the annual fire extinguisher inspection was certified.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed portable fire extinguisher inspection deficiencies.

Plan of Correction - To be completed: 04/16/2024

1a. The signature of the individual performing the certification is in the maintenance office files.

1b. The documentation of the person that conducted the annual fire extinguisher inspection is located in the maintenance office files.

The Maintenance Director and technician were educated to maintain this documentation in their files.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of fifteen smoke compartments.

Findings include:

1. Observation on March 12, 2024, at 9:18 a.m., revealed the door to resident room 327 had a large gap at the top and side when fully closed and latched in its frame and could not resist the passage of smoke.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed corridor door deficiency.

Plan of Correction - To be completed: 04/16/2024

1. The door jam was adjusted to ensure there is no large gap at the top and side of the door when fully closed and latched in its frame and so that is can resist the passage of smoke.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of fifteen smoke compartments.

Findings include:

1. Observation on March 12, 2024, at 10:31 a.m., revealed an unsealed pipe penetration in the smoke barrier wall, above the ceiling at the smoke barrier doors, by the beauty salon on the first floor.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed smoke barrier wall deficiency.

Plan of Correction - To be completed: 04/16/2024

1. The penetration above the ceiling at the smoke barrier doors by the beauty salon was sealed with a UL approved through penetration fire stop system.

The Maintenance Director or technician will ensure vendors seal their penetrations with an approved fire rated materials and/or with UL approved through penetration fire stop systems.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911
Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of fifteen smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code...19.5.1.1, NFPA 101.

Findings include:

1. Observation on March 12, 2024, at 11:00 a.m., revealed an open electrical junction box in the maintenance room behind the air handler unit.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed electrical wiring deficiency.

Plan of Correction - To be completed: 04/16/2024

1. The electrical cover plate was re-applied to the electrical junction box in the maintenance room.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator testing and maintenance requirements in two instances affecting the entire facility.

Findings include:

1. Review of documentation on March 12, 2024, revealed the following emergency generator testing deficiencies:

a) 12:30 p.m., the facility lacked documentation for the monthly test/function of the transfer switch for January and February 2024;
b) 12:32 p.m., the facility failed to perform the required annual fuel quality testing in the past twelve months. The most recent fuel quality testing was performed on February 21, 2023.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the above-listed emergency generator testing deficiencies.

Plan of Correction - To be completed: 04/16/2024

1a. Education was provided to the Maintenance Director and the technician that the seconds to engage the transfer switch needs to be documented when performing the monthly test. Review of transfer switch testing will be completed monthly by the Maintenance Director of designee and the results will be brought to the QAPI Committee Meeting monthly for three months.

1b. The annual fuel quality testing was completed on March 15, 2024 and the records are maintained in the maintenance office records.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920
Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of fifteen smoke compartments.

Findings include:

1. Observation on March 12, 2024, at 9:10 a.m., revealed a microwave plugged into a power strip in the DON office.

Interview with the Facility Administrator and the Maintenance Director on March 12, 2024, at 1:45 p.m. confirmed the listed electrical wiring systems and equipment deficiency.

Plan of Correction - To be completed: 04/16/2024

1. The microwave was unplugged from the power strip and plugged into an approved outlet. Maintenance has been educated on not plugging a microwave into a power strip.

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