Nursing Investigation Results -

Pennsylvania Department of Health
ROSEMONT CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSEMONT CENTER
Inspection Results For:

There are  31 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.
ROSEMONT CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 29, 2019, it was determined that Rosemont Care and Rehabilitation Center was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(a) REQUIREMENT Develop EP Plan, Review and Update Annually: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.
[The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.]

* [For hospitals at 482.15 and CAHs at 485.625(a):] The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

The emergency preparedness program must include, but not be limited to, the following elements:]
(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on May 29, 2019, between 8:30 am and 11:00 am, revealed the facility failed to provide an emergency preparedness plan, which is one part of the emergency preparedness program, that identified the framework for the following:

A. Facility-based and community-based risk assessment that will assist a facility in addressing the needs of their patient populations;
B. Identifying the continuity of business operations which will provide support during an actual emergency;
C. The plan must support, guide, and ensure a facility's ability to collaborate with local emergency preparedness officials, specific to the surrounding area.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the lack of documentation.








 Plan of Correction - To be completed: 07/12/2019

The facility-based and community based risk assessment has been completed. All components of the plan, including identifying the continuity of business operations which will provide support during an actual emergency have been completed.

The plan will be reviewed annually, at a minimum, both internally and with local emergency authorities. Results of the review will be taken to the quality assurance performance improvement committee for review and recommendations. The administrator or designee will be responsible for this process.
483.73(a)(1)-(2) REQUIREMENT Plan Based on All Hazards Risk Assessment:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

*[For LTC facilities at 483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

*[For ICF/IIDs at 483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on May 29, 2019, between 8:30 am and 11:00 am, revealed the facility failed to provide an emergency preparedness plan that included the following:

a. Community based risk assessment;
b. Facility based risk assessment.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the documentation was unavailable.









 Plan of Correction - To be completed: 07/12/2019

A community based and facility based risk assessment has been completed. The quality assurance performance improvement committee will review the assessments annually, at a minimum, and provide any recommendations. The administrator or designee will be responsible for this process.
483.73(a)(4) REQUIREMENT Local, State, Tribal Collaboration Process:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the dialysis facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Name: - Component: -- - Tag: 0009

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on May 29, 2019, between 8:30 am and 11:00 am, revealed the facility failed to provide an emergency preparedness plan that identified efforts to contact officials to engage in collaborative planning for an integrated emergency response.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the lack of documentation.










 Plan of Correction - To be completed: 07/12/2019

The facility will contact local officials to engage in collaborative planning for an integrated emergency response, and document these efforts. The administrator or designee will be responsible for this process.
483.73(b) REQUIREMENT Development of EP Policies and Procedures: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.
(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.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at 460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least annually.

*[For ESRD Facilities at 494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.
Observations:
Name: - Component: -- - Tag: 0013

Based on document review and interview, it was determined the facility failed develop an emergency preparedness plan, affecting the entire facility.

Findings Include:

1. Document review on May 29, 2019, between 8:30 am and 11:00 am, revealed the facility failed to provide verification an emergency preparedness plan had been developed and policies and procedures reviewed; scheduled to be updated on an annual basis.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the lack of documentation.









 Plan of Correction - To be completed: 07/12/2019

An emergency preparedness plan has been updated, as have the policies and procedures. This plan, policies, and procedures, will be reviewed annually, at a minimum. Documentation of the review, and any recommended changes will be taken to the quality assurance performance improvement committee for review and recommendations. The administrator, or designee will be responsible for this process.
483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and Patients:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on May 29, 2019, between 8:30 am and 11:00 am, revealed the facility failed to provide an an emergency plan that provides for adequate subsistence for all patients and staff during an emergency, which includes the following:

a. Provisions, including, but not limited to, food, pharmaceuticals and medical supplies;
b. Storage of provisions less likely to be affected by disaster;
c. Consider the possibility that volunteers, visitors, and individuals from the community may arrive at the facility to offer assistance or seek shelter;
d. Alternate sources of power to maintain temperatures, emergency lighting, fire detection, extinguishing systems, and sewage and waste disposal;

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the lack of documentation.









 Plan of Correction - To be completed: 07/12/2019

The emergency plan has been updated to include emergency provision requirements for residents and staff. This includes food, medical supplies and pharmaceuticals. Further, the plan has been updated to include potential visitors that may need to seek shelter. The plan also includes the use of alternate sources of power. This plan will be reviewed annually, at a minimum, with results of the review taken to the quality assurance performance improvement committee for review and recommendations. The administrator or designee will be responsible for this process.
483.73(d) REQUIREMENT EP Training and Testing:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

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

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

Based on document review and interview, it was determined the facility failed to ensure the facilities developed an emergency preparedness training and testing program that was based on the emergency plan affecting the entire facility.

Findings include:

Document review on May 29, 2019, between 8:30 am and 11:00 am, revealed there was no documentation available indicting facility developed an emergency preparedness training and testing program that was based on the emergency plan.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed documentation was unavailable.












 Plan of Correction - To be completed: 07/12/2019

The facility will develop emergency preparedness training and testing based on the emergency plan. The training and testing will be reviewed annually, at a minimum, with the results of the review taken to the quality assurance performance improvement committee for review and recommendations. The administrator or designee will be responsible for this process.
483.73(d)(2) REQUIREMENT EP Testing Requirements:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

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

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

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

Based on document review and interview, it was determined the facility failed to ensure the facility conducted exercises to test the emergency plan at least annually effecting the entire facility.

Findings include:

Document review on May 29, 2019 between 8:30 am and 11:00 am, revealed the facility failed to conducted exercises to test the emergency plan by participate in a full-scale exercise community-based; or an individual, facility-based exercise and that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed documentation was unavailable.









 Plan of Correction - To be completed: 07/12/2019

An exercise to test the emergency plan will be conducted. This test will include group discussion, and will be based on a relevant emergency scenario. Results of the exercise will be taken to the quality assurance performance improvement committee for review and discussion. The administrator or designee will be responsible for this process.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #181402
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2019, it was determined that Rosemont Care and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 III (200), unprotected ordinary structure, which is fully sprinklered.




 Plan of Correction:


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

Based on observation and interview, it was determined the following item did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within this component.

Findings include:

1. Observation made on May 29, 2019, at 9:00 am, revealed the facility failed to supply the required portable, accurate floor plans identifying smoke barrier walls, fire walls, shafts, hazardous areas, exits, etc. for the Life Safety Survey.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the facility did not have accurate floor plans.

2. Observation made on May 29, 2019, at 1:45 pm, revealed that the facility failed to annually inspect battery operated carbon monoxide alarms in close proximity to fossil fuel-burning devices within ground floor boiler room which houses natural gas boilers, hot water convertors that was last inspected and labeled on December 5, 2017.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed documetation was unavailable.







 Plan of Correction - To be completed: 07/12/2019

Floor plans are being updated to include smoke barrier walls, fire walls, shafts, hazardous areas, exits, etc.

The batteries have been changed on the carbon monoxide alarms. The carbon monoxide alarms will be inspected at least annually, and the batteries will be changed at least annually. The director of maintenance will be responsible for this process.
NFPA 101 STANDARD Building Construction Type and Height: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.
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 BUILDING 01 - Component: 01 - Tag: 0161

Based on documentation review and interview, it was determined the facility failed to maintain the fire resistance rating for building construction affecting the entire facility.

Findings Include:

1. Observation and documentation review on May 29, 2019, between 8:30 am and
2:00 pm, revealed the facility was a three-story building, Type III (200), Unprotected Ordinary construction. The permitted story height for this construction type is one story therefore; the facility story height exceeds the maximum allowed.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm,
confirmed the construction type.







 Plan of Correction - To be completed: 07/12/2019

No residents have been affected by this deficiency. The facility is requesting a TLW be granted to Rosemont Center from to provide time for the facility to determine the best solution to correct the building construction type, secure the necessary funding, obtain a contractor to perform the work, develop architectural drawings for submittal and approval and lastly, to perform the work required.

The facility has requested the Division of Life Safety/Safety Inspection Department to evaluate the building through the Fire Safety Evaluation System (FSES).

The maintenance department will continue to monitor life safety in the facility as required by regulations and any changes to the structure or the building will be reported to Life Safety for review to stay within the required standards.

This deficiency will be reviewed in QAPI monthly monitoring on progress


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 BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to ensure egress doors with delayed-egress locking systems released as signed, on one of three levels.
Findings include:

1. Observation on May 29, 2019, at 12:45 pm, revealed, in Main Lobby the delayed-egress double doors to stair tower # 1 failed to release after 15 seconds as indicated on signage.
Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the door failed to release.








 Plan of Correction - To be completed: 07/12/2019

No residents have been harmed from this deficiency.

Testing of this door confirmed that the door is wired into the fire system, and is not a delayed egress door. The sign indicating that it is a delayed egress door has been removed.

All egress doors will be inspected to assure proper signage. Results of the inspection will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will be responsible for this process.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




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

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

Findings include:

1. Observation on May 29, 2019, at 12:50 pm, revealed, the lobby stair tower had an unsealed penetration around a sprinkler pipe.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the unsealed penetration of the stair tower enclosure.






 Plan of Correction - To be completed: 07/12/2019

No residents have been harmed from this deficiency. The penetration has been sealed. A visual inspection will be conducted to ensure that there are no more penetrations around sprinkler pipes. A through penetration fire stop system will be used to seal any penetrations found. Results of this inspection will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will be responsible for this process.
NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, and maintained in operable condition, affecting one of one emergency battery back-up light.

Findings include:

1. Document review on May 29, 2019 at 10:30 am, revealed, documentation verifying monthly and annual 90-minute testing of the back-up lighting in was not available at time of survey.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the documentation was not available.

2. Observation on May 29, 2019, at 1:15 pm, revealed the generator battery back-up light failed to illuminate when tested.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the battery back-up light failed to illuminate when tested.










 Plan of Correction - To be completed: 07/12/2019

Monthly testing and annual 90 minute testing have been completed. Battery back up light has been ordered and will be installed upon receipt.

Monthly testing of the generator, and annual 90 minute testing, as well as monthly inspection of the light will be conducted, and recorded.

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

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

Based on observation and interview, it was determined the facility failed to maintain doors protecting hazardous areas on one of three floors.

Findings include:

1. Observation on May 29, 2019, revealed, 2nd floor Soiled Linen Room door failed to close and latch when tested.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the door failed to close and latch when tested.






 Plan of Correction - To be completed: 07/12/2019

The second floor soiled linen room door has been repaired, and properly closes and latches.

In order to prevent this from occurring in the future, all doors with latches will be audited monthly, for a period of three months, to identify other doors that may need repaired. Results of this audit will be sent to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will be responsible for this audit.
NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected at required intervals, in one of two instances.

Findings include:

1. Document review on May 29, 2019, at 10:30 am, revealed the facility could not produce documentation showing that a kitchen suppression system inspection was performed within 6 months of the January 2019 inspection.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the missing documentation.








 Plan of Correction - To be completed: 07/12/2019

The kitchen suppression system was inspected June 12, 2019, and found to be in proper working order.

The kitchen suppression system will be inspected every six months. An audit will be conducted semiannually to ensure the inspection occurs according to requirements. Results of this audit will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will be responsible for this audit.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain fire alarm system components, affecting the entire facility.

Findings include:

1. Document review on May 29, 2019, at 9:00 am, revealed documentation of smoke detector sensitivity testing was unavailable at time of survey.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed smoke detector sensitivity testing was not available at time of survey.

2. Document review on May 29, 2019, at 9:10 am, revealed documentation of semi-annual fire alarm testing was not available at time of survey.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed documentation of semi-annual fire alarm testing was unavailable at time of survey.







 Plan of Correction - To be completed: 07/12/2019

The facility will have smoke detector sensitivity testing completed, as well as a semi-annual fire alarm testing.

An audit will be conducted semiannually to ensure the fire alarm testing is completed, and to ensure the smoke detector sensitivity testing is completed. Results of this audit will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will be responsible for this audit.
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 BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined that the facility failed to ensure that automatic sprinkler system components are inspected and maintained at the required intervals, affecting the entire facility

Findings include:

1. Document review on May 29, 2019, at 9:20 am, revealed the facility could not produce documentation showing quarterly sprinkler inspections had been performed for the 2nd and 4th quarters of 2018.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the missing quarterly sprinkler inspections.







 Plan of Correction - To be completed: 07/12/2019

No resident was harmed from this deficiency. The automatic sprinkler system has a pressure switch type waterflow alarm device. Semi-annual sprinkler inspection has been scheduled. Semi-annual sprinkler monitoring will be done by the director of maintenance or designee, and results of the monitoring will be taken to the quality assurance performance improvement committee for review and recommendations.
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 BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain that the doors protecting corridor openings positivey latch, affecting three of five smoke zones within this component.

Findings:

1. Observation made on May 29, 2019, between 11:50 am and 1:15 pm, revealed that the following corridor doors failed to positively latch into the frame.

a. 11:50 am, second floor room 212.
b. 12:45 pm, first floor room 111.
c. 1:15 pm, ground floor beauty salon.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the above stated doors failed to latch.





 Plan of Correction - To be completed: 07/12/2019

No residents were harmed from this deficiency.

The identified doors have been repaired and are positively latching.

An audit of all doors that are to positively latch will be conducted. Results of the audit will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will be responsible for this process.
NFPA 101 STANDARD HVAC:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on May 29, 2019, at 10:45 am, revealed the August 4, 2017, Fire Damper Inspection Report listed dampers as deficient or not accessible. Proof of deficiencies corrected was not available at time of survey.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed fire damper inspection documentation showing the deficiencies were corrected, was not available at time of survey.






 Plan of Correction - To be completed: 07/12/2019

No residents were harmed from this deficiency. Facility will have a fire damper inspection report, that includes proof of deficiencies corrected. This inspection will be incorporated into the quality assurance performance improvement process for review and recommendations. The director of maintenance or designee will be responsible for this process.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to perform an annual fire door inspection, for one of one required inspection.

Findings include:

1. Document review on May 29, 2019, at 11:15 am, revealed the facility could not produce documentation showing that an annual fire door inspection was performed.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed documentation of the annual rated door inspection was not available at time of survey.





 Plan of Correction - To be completed: 07/12/2019

No residents were harmed from this deficiency. An annual door inspection will be conducted. Results of the inspection will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will oversee this process.
NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring on two of three levels.

Findings include:

1. Observation on May 29, 2019, between 11:45 am, and 1:00 pm, revealed electrical panels with missing circuit breaker protective blanks in the following locations:

a. 11:45 am, 2nd floor Nurses Station.
b. 1st floor Nurses Station.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the missing protective blanks.










 Plan of Correction - To be completed: 07/12/2019

No residents were harmed from this deficiency. Protective blanks will be installed in the breaker panel. An inspection of all breaker panels will be conducted monthly to ensure protective blanks are in place. The results of this inspection will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will oversee this process.
NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations within this facility.

Findings include:

Document review on May 29, 2019, at 10:55 am, revealed the facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the previous 12 months.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the documentation was unavailable at time of survey.




 Plan of Correction - To be completed: 07/12/2019

No residents were harmed from this deficiency. Annual receptacle testing will be completed in patient care rooms at bed locations. Results of this testing will be taken to the quality assurance performance improvement committee for review and recommendation. The director of maintenance or designee will be responsible for this inspection.
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 BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

1. Document review on May 29, 2019 at 10:20 am revealed the facility could not produce documentation for the following required testing and inspections of the emergency generator, since September 2018:

a. Monthly 30-minute full load exercise.
b. Weekly visual inspection.
c. Weekly battery electrolyte checks.
d. Monthly specific gravity testing.
e. 3-year 4-hour exercise.
f. Preventative Maintenance identifying No evidence of wet-stacking.

Interview at the exit conference with the Administrator on May 29, 2019, at 2:15 pm, confirmed the missing testing and inspections.







 Plan of Correction - To be completed: 07/12/2019

No residents were harmed from this deficiency. A monthly 30 minute full load exercise, 3-year 4-hour exercise was conducted. A weekly visual inspection, weekly battery electrolyte check, and preventative maintenance has been conducted. The facility will maintain records for these duties. Results of the generator maintenance will be taken to the quality assurance performance improvement committee for review and recommendations. The director of maintenance or designee will oversee this process.

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