Nursing Investigation Results -

Pennsylvania Department of Health
STATESMAN HEALTH & REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
STATESMAN HEALTH & REHABILITATION CENTER
Inspection Results For:

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STATESMAN HEALTH & REHABILITATION 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 April 8, 2019, it was determined that Statesman Health & Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(a)(3) REQUIREMENT EP Program Patient Population:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(3) Address patient/client population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*Note: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC, FQHC, or ESRD facilities.]
Observations:
Name: - Component: -- - Tag: 0007

Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness plan to include specifying the population served within the facility, persons at risk, and types of services provided during an emergency, affecting the entire facility.

Findings include:

1. Document review on April 8, 2019, at 10:35 am, revealed the facility lacked a written Emergency Preparedness Plan to include specifying the population served within the facility, persons at risk, and types of services provided during an emergency.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the Emergency Preparedness plan did not identify the population served.








 Plan of Correction - To be completed: 04/29/2019

0007-Population served within the facility, persons at risk, and types of services provided has been added to the Emergency Manual. Staff educated on this additional information to the Emergency Plan Manual. A bi-annual review of the Emergency Plan Manual will be completed by Administrator and Maintenance Director.
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 that the facility failed to develop an Emergency Preparedness plan that includes the provision of subsistence needs for staff and residents, for the duration of the emergency, affecting the entire facility.

Findings include:

1. Document review on April 8, 2019, at 10:50 am, revealed the facility lacked a written subsistence plan to include the following information:

a. Provisions for food, water, medical and pharmaceutical supplies.
b. Provisions for sewage and waste disposal.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the Emergency Preparedness plan did not include all required provisions.



 Plan of Correction - To be completed: 04/29/2019

0015-A written subsistence plan to include provisions for food, water, medical, pharmaceutical supplies, sewage and waste disposal has been added to the Emergency Plan Manual. Staff educated on this additional information to the Emergency Plan Manual. A bi-annual review of the Emergency Plan Manual will be completed by the Administrator and Maintenance Director.
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 develop an Emergency Preparedness testing program to conduct exercises to test the emergency plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 8, 2019, at 11:10 am, revealed the Emergency Preparedness plan did not include a tabletop exercise of their emergency plan.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the EP plan did not include all required testing of the emergency plan.





 Plan of Correction - To be completed: 04/29/2019

0039-Tabletop exercise, completed in October 2018, was added to the Emergency Plan Manual. Maintenance Director and assistant educated that this tabletop exercise must be implemented into the Emergency Plan Manual. A bi-annual review of the Emergency Plan Manual will be completed by the Administrator and Maintenance Director.
Initial comments:Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0000


Facility ID# 193702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 8, 2019, it was determined that Statesman Health & Rehabilitation Center - Main Building, 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 one-story, Type II (000), unprotected non-combustible structure, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Smoke Detection:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain the ceiling integrity, which could delay the activation of the smoke detector, affecting one of five smoke compartments.

Findings include:

1. Observation on April 8, 2019, at 3:00 pm, revealed, in D-wing heater room, there was an unsealed penetration of the ceiling assembly around a pipe.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the unsealed penetration.





 Plan of Correction - To be completed: 04/29/2019

0347-Unsealed penetration in D wing heater room sealed with 3M Fire Barrier Sealant, CP 25WB+. Maintenance Director and assistant educated on the risks of unsealed penetrations and maintaining the ceiling integrity. Random audits of maintaining the ceiling integrity will be completed by the Maintenance Director /designee weekly x60days, and bi-weekly x30days, and after any vendor who performed work in these areas. Results will be reported to the QAPI committee for review and resolution.
NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were accessible and inspected at required intervals, affecting one of five smoke compartments.

Findings include:

1. Observation on April 8, 2019, at 2:05 pm, revealed the wall mounted portable fire extinguisher in the lobby vestibule had missed the March 2019 monthly quick check inspection.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the missing monthly quick check.


2. Observation on April 8, 2019, at 2:55 pm, revealed in the kitchen, access to the wall mounted portable K-type fire extinguisher was obstructed by several stored food carts.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the obstructed fire extinguisher.




 Plan of Correction - To be completed: 04/29/2019

0355-Food carts immediately moved away from the Fire extinguisher. Dietary staff educated on access/not to block the Fire Extinguishers with Food Carts or other apparatus. Audits will be performed by the Maintenance Director/designee weekly x 60 days and bi-weekly x 30days. Results of the audits will be reported to the QAPI committee for review and resolution.

Fire Extinguisher in the vestibule immediately inspected. Facility Fire extinguishers also inspected. Maintenance Director educated to have a fire extinguisher check off list for his monthly inspection to prevent future recurrence. Fire extinguishers will be tested monthly and check off list utilized. Results will be reported to the QAPI committee for review and resolution.
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 BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls, affecting four of five smoke compartments.

Findings include:

1. Observations on April 8, 2019, between 2:00 pm and 2:15 pm, revealed unsealed
penetrations of the smoke barrier walls in the following locations:

a. 2:00 pm, A-wing, above smoke doors by medical records room, around MC cable;
b. 2:15 pm, B-wing, above smoke doors by business office, around data lines.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the unsealed penetrations.





 Plan of Correction - To be completed: 04/29/2019

0372-Unsealed penetrations above the smoke doors in A and B wing sealed with 3M Fire Barrier Sealant, CP 25WB+. Fire Stop System Number C-AJ-3137. Random audits of maintaining the integrity of smoke barrier walls will be completed by the Maintenance Director /designee weekly x 60 days, and bi-weekly x 30days, and after any vendor who performed work in these areas. Results of the audits will be reported to the QAPI committee for review and resolution.

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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to perform required fire door inspections, affecting the entire facility.

Findings include:

1. Document review on April 8, 2019, at 9:45 am, revealed the facility could not provide documentation showing an annual fire door inspection had been performed.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed documentation of the annual rated door inspection was not available at time of survey.





 Plan of Correction - To be completed: 04/29/2019

0761-Annual Fire Door Inspection and repairs completed. Maintenance Director and assistant educated on Annual Fire Door Inspections/Requirements. Fire Doors will be randomly audited weekly x 60days and biweekly x 30days. Annual inspection of the Fire Doors will be annual and repairs completed as needed. Results of the audits will be reported to the QAPI committee for review and resolution.
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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain required receptacle testing at resident care rooms, affecting all resident bed locations within the facility.

Findings include:

1. Document review on April 8, 2019, at 9:50 am, revealed the facility was unable to provide documentation showing annual receptacle testing at resident bed locations was performed during the previous 12 months.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the documentation was unavailable at time of survey.




 Plan of Correction - To be completed: 04/29/2019

0914-Annual Receptacle testing and repairs in resident care rooms completed. Maintenance Director and assistance educated on Annual Receptacle Inspection/Requirements. Receptacles will be randomly tested weekly x 60days and bi-weekly x 30 days. Annual Receptacle testing will be annual and repairs completed as needed. Results of the audits will be reported to the QAPI committee for review and resolution.
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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required inspections/testing of the emergency generator, affecting the entire facility.

Findings include:

1. Document review on April 8, 2019, at 9:20 am, revealed the facility could not produce documentation from February 6, 2019 through April 8, 2019, for the emergency generator:

a. Monthly 30-minute full load exercise;
b. Weekly visual inspections;
c. Weekly generator battery voltage checks.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the facility could not produce documentation for the required testing and inspections.






 Plan of Correction - To be completed: 04/29/2019

0918-Emergency Testing completed on the Generator. Maintenance Director and assistant educated that a monthly 30 minute full load exercise, weekly visual inspection and weekly generator battery voltage checks must be completed on the facility generator. NHA will audit the weekly testing of generator x 90 days. Results of the audits will be reported to the QAPI committee for review and resolution.
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 BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of extension cords, affecting one of five smoke compartments.

Findings include:

1. Observation on April 8, 2019, at 2:10 pm, revealed, in the lobby under the receptionist desk, there was an orange extension cord in use.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the unauthorized use of an extension cord.




 Plan of Correction - To be completed: 04/29/2019

0920-Orange extension cord removed and hard wiring installed. Maintenance Director and designee educated that extension cords are not to be used as a substitute for fixed wiring. Common areas will be randomly audited for extension cords weekly x 60 days and bi-weekly x 30 days. Results of the audits will be reported to the QAPI committee for review and resolution.
Initial comments:Name: BUILDING 02 (PHYSICAL THERAPY BUILDING) - Component: 02 - Tag: 0000


Facility ID# 193702
Component 02
Physical Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 8, 2019, it was determined that Statesman Health & Rehabilitation Center - Physical Therapy Addition, 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 one-story, Type V (111), protected wood frame structure, which is fully sprinklered.



 Plan of Correction:


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: BUILDING 02 (PHYSICAL THERAPY BUILDING) - Component: 02 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain egress doors with delayed-egress locking systems, affecting one of two exit discharges within this component.

Findings include:

1. Observation on April 8, 2019, at 1:50 pm, revealed the delayed-egress door inside Physical Therapy, failed to release after 15 seconds when tested, and as indicated on the posted signage.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the delayed egress door failed to release when tested.




 Plan of Correction - To be completed: 04/29/2019

0222-Egress Door in Physical Therapy adjusted and releases after 15 seconds. Maintenance Director and assistant educated on maintaining egress doors with delayed-egress locking systems. Egress Doors will be randomly audited for 15 second release weekly x 60 days and bi-weekly x30 days. Results of the audits will be reported to the QAPI committee for review and resolution.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: BUILDING 02 (PHYSICAL THERAPY BUILDING) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to install required sprinkler system components, affecting two of six rooms within this building.

Findings include:

1. Observation on April 8, 2019, at 2:05 pm, revealed missing sprinkler escutcheons in the following locations:

a. 1:20 pm, Physical Therapy bathroom;
b. 1:30 pm, Physical Therapy modality room.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 3:00 pm, confirmed the missing escutcheons.





 Plan of Correction - To be completed: 04/29/2019

0353-Escutcheons installed on the Sprinklers in Physical Therapy Bathroom and Modality Room. Maintenance Director and designee educated on the importance of each sprinkler having an escutcheon. Random audits will be completed on the sprinkler heads/escutcheons weekly x60 days and bi-weekly x 30 days. Results of the audits will be reported to the QAPI committee for review and resolution.

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