Nursing Investigation Results -

Pennsylvania Department of Health
GLENDALE UPTOWN HOME
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GLENDALE UPTOWN HOME
Inspection Results For:

There are  28 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.
GLENDALE UPTOWN HOME - 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 Glendale Uptown Home was not in compliance with the requirements of 42 CFR 483.73.


 Plan of Correction:


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

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

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

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

Findings Include:

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

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the documentation was not available.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Emergency policy and procedure has been updated to include CMS 1135 waiver. Facility 1135 includes; providing nursing staff to alternate care site to provide care to our residents transferred, providing necessary medications until alternative site can make arrangement to supply medication, supply of medical equipment if alternative facility does not have enough equipment to meet the needs and care of our residents transferred to their facility etc.

Facility will provide waiver to facilities that facility has joint agreement for patient transfer during disaster and public emergency

NHA/SDC will educate staff on CMS 1135 waiver as part of facility policy on emergency preparedness

NHA will audit facility emergency preparedness during yearly review to ensure that it includes facility policy for CMS 1135 waiver
483.73(d) REQUIREMENT EP Training and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

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

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

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

Findings include:

1. Document review on April 8, 2019, at 8:00 am, revealed the facility failed to develop an
Emergency Preparedness training program.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 04/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements

Staff education completed on facility's emergency preparedness training procedure completed

Facility written emergency plan has been included in the emergency preparedness plan

Staff development coordinator re-educated on regulation regarding required emergency preparedness training

NHA will schedule and audit emergency preparedness training at least twice a year for all staff and with new employee orientation

Audit results will be presented at quarterly QAPI consisting of interdisciplinary team until substantial compliance is achieved
483.73(d)(1) REQUIREMENT EP Training Program:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
(1) Training program. The [facility, except CAHs, ASCs, PACE organizations, PRTFs, Hospices, and dialysis facilities] must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For Hospitals at 482.15(d) and RHCs/FQHCs at 491.12:] (1) Training program. The [Hospital or RHC/FQHC] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For Hospices at 418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least annually.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.

*[For PRTFs at 441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.

*[For PACE at 460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.

*[For CORFs at 485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.

*[For CAHs at 485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CMHCs at 485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least annually.

Observations:
Name: - Component: -- - Tag: 0037

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

Findings include:

1. Review of documentation on April 8, 2019 at 8:00 am, revealed the facility failed to perform training on the Emergency Preparedness plan that included the following:

a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role;
b. Provide emergency preparedness training at least annually;
c. Maintain documentation of the training;
d. Demonstrate staff knowledge of emergency procedures.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements

Documentation for staff training about facility emergency preparedness provided to NHA by staff development director
Staff documented education includes; Initial emergency preparedness, annual emergency training, and demonstration of staff knowledge of procedure.
Facility emergency preparedness documentation is maintained electronically and manually in a binder

NHA verified that staff training were provided annually according to facility emergency preparedness policy and procedures

SDC will complete quarterly audit for emergency preparedness training to ensure that all new staff completed initial training during orientation, current staff completed yearly training and demonstrate knowledge of facility emergency preparedness

Results of audit finding will be presented at the quarterly QAPI comprising of interdisciplinary team until substantial compliance achieved
483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

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

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

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

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

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

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

Findings include:

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

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the documentation was not available.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements

NHA will update facility emergency preparedness policy to include agreement or contract with secondary fuel supplier for facility emergency generator

NHA will educate Maintenance director about #0041 regulation to ensure that there is always a back secondary agreement with a fuel supplier for emergency generator

NHA will audit facility agreement quarterly to ensure that there is always a secondary fuel supplier for emergency generator

NHA will present audit findings at quarterly QAPI comprising of IDT team until substantial compliance is achieved
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 210102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 08, 2019, it was determined that Glendale Uptown Home was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90 (a).

This is a four-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.



 Plan of Correction:


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

Based on observation, document review and interview, it was determined the facility failed to provide a set of accurate portable life safety floor plans, affecting the entire facility.

Findings include:

1. Document review on April 8, 2019, at 8:00 am, revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection requires that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey. (Repeat Deficiency).

The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Hazardous Areas;
e. Required Exits should be clearly noted; and
f. Shafts Walls.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed portable accurate floor plans were not available.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

Facility plan drawing revision illustrating smoke barriers walls, fire barrier walls, horizontal exits, hazardous areas, required exits and shafts submitted to APS vendor for revision and reprint
Administrator will ensure that facility drawing plan are up to date and meet NEPA 101 general requirement
Administrator/Maintenance director will check new facility drawing once received monthly to ensure that it meets regulatory guidelines
Maintenance director will be adding this tag the monthly QAPI report until compliance has been met for two consecutive months.



























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 the smoke resistance rating of hazardous areas, in sprinklered locations, affecting one of five levels within the facility.

Findings include:

1. Observation made on April 8, 2019, at 12:10 pm, 4th floor, revealed the door to the soiled utility room near resident room 430 had a gap between the door frame, which would not limit the passage of smoke.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the gap between the door and door frame.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements

A work order was created to assess the inch gap in the door frame of the soiled utility room near room 430.

The inch gap in the doors on the 4th repair completed by maintenance staff on 4/30/2019 to ensure the capability of resisting the passage of smoke into the other rooms. The door closure was adjusted and a piece of weather stripping was used to seal the gap

Maintenance inspected all hazardous areas doors for gap between door frame exceeding inch on 4/12/19 and no doors found not meeting the inch gap requirement
A monthly inspection of hazardous room doors will be completed by Maintenance director to ensure that gap between door frame is less than inch
The maintenance director will present hazardous doors inspection results at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved

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 portable fire extinguishers and fire suppression systems were inspected at required intervals, affecting one of five levels within the facility.
Findings include:
1. Observation made on April 8, 2019, at 1:20 pm, main kitchen, revealed the monthly-quick inspection tag for the portable K type fire extinguisher had a missed quick-check inspection for March 2019.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the monthly quick-check was missed.


2. Observation made on April 8, 2019, at 1:25 pm, main kitchen, revealed the monthly-quick inspection tags for the two fire suppression pull stations were blank.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the monthly pull station quick-checks were missed.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Monthly quick inspection completed for K type extinguisher and tag dated
Monthly quick inspection tag for kitchen fire suppression completed and dated
Inspection of other fire extinguishers completed on 4/10/19 and no deficiency identified
Maintenance director will complete monthly inspection of fire extinguisher and fire suppression for quick check inspection and date
Maintenance director will present results of monthly fire extinguisher inspection to QAPI
comprising of interdisciplinary team until substantial compliance is achieved



NFPA 101 STANDARD Fire Alarm System - Initiation: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.
Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting two of fourteen smoke zones within the facility.

Findings include:

1. Observations made on April 8, 2019, between 11:45 am and 1:05 pm, revealed heat detectors dislodged from the ceiling assembly in the following locations:

a. 11:45 am, 1st floor, inside the Administrator's office;
b. 1:05 pm, 2nd floor, inside resident room number 221.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the dislodged heat detectors in the above named locations.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Dislodged heat detectors in administrator's office and 2nd floor, room 221 repair completed on 4/9/2019 by maintenance staff
Inspection of all heat detectors for dislodgment completed by maintenance staff on 4/24/19 and no new heat dislodgement found

Maintenance director/designee will complete 20% of all heat detectors inspection for dislodgement monthly
Report of heat detector dislodgement inspection will be present at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved
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 - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain a smoke resistant ceiling assembly, in conjunction with the installation of smoke detectors, affecting three of fourteen smoke zones within the facility.

Findings include:

1. Observation made on April 8, 2019, at 12:30 pm, 4th floor, revealed in the corridor near resident room number 403, there was a smoke detector dislodged from the ceiling assembly.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed dislodged smoke detector.


2. Observations made on April 8, 2019, between 12:45 am and 1:10 pm, revealed unsealed ceiling tile penetrations near smoke detectors, in the following locations:

a. 12:45 pm, 3rd floor, inside the housekeeping utility room near resident room number 308;
b. 1:10 pm, 2nd floor, inside the storage room across from resident room number 250.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the condition of the smoke detectors in the above named locations.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Repairs to dislodged smoke detector on 4th floor corridor by room 403 repaired on 4/9/2019. The bracket holding smoke detector was adjusted.
Unsealed ceiling tile penetrations near smoke detectors on 3rd floor inside housekeeping utility room number 308, was repaired using gap sealer, 2nd floor, inside the storage room across from resident room 250 repair completed on 4/9/19. Ceiling tile was replaced to eliminate gaps.
House wide Ceiling inspection for penetrations competed by maintenance director on 4/26/19 did not reveal any new penetration.
Maintenance director will inspect 20% of ceiling tile for penetrations and dislodged smoke detector monthly. Repair will be completed at the time of audit
Maintenance director will present ceiling tile inspection report at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved

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

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components in operable condition, affecting the entire facility.

Findings include:

1. Document review on April 8, 2019, at 8:00 am, revealed the annual sprinkler inspection report dated September 7, 2018 listed multiple sprinkler system deficiencies that had not been repaired:

a. Outdated heads in the basement (over 50 years old);
b. Drain piping leaks badly during drain test, needs to be replaced;

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the automatic sprinkler system deficiencies have not been repaired.








 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Outdated sprinkler heads in the basement replacement and repair of leaking drain pipe was completed on 4/25/19
Cintas inspection completed during repair did not show any other outdated sprinkler heads or leaking drain pipes
Cintas will complete inspection and maintenance of sprinkler heads and pipes quarterly. Report of quarterly inspection will be provided to Director of maintenance
Maintenance director will present report of Cintas findings at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to maintain required certifications for fire extinguishers, affecting the entire building.

Findings Include:

1. Documentation reviewed on April 8, 2019, at 8:00 am, revealed the facility was unable to provide certifications for persons performing maintenance and recharging of fire extinguishers.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed fire extinguisher inspection certifications were not available at the time of survey.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Certification for service provider technician performing maintenance and recharging of fire extinguishers requested from provider on 4/8/2019
NHA will re-educate maintenance staff about requesting for technician certification before and after completion of recharging of fire extinguishers
Maintenance director will complete monthly audit of fire extinguisher maintenance binders for technician certification monthly
Maintenance director will present results of technician certification binders at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved
NFPA 101 STANDARD Portable Space Heaters: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 Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0781

Based on interview and document review it was determined that the facility failed to prohibit the use of portable electric space heaters, affecting one of five levels within the facility.

Findings include:

1. Observation made on April 8, 2019, at 1:00 pm, 2nd floor, revealed the prohibited use of a portable electric space heater inside the Social Services office near resident room number 235. Verification was not provided that heating elements do not exceed 212 degrees Fahrenheit.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed a portable electric space heater was in use.








 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Portable electric space heater was removed from social service office on 4/8/19
Maintenance director completed audit of all offices and resident rooms for electric portable heaters on 4/9/2019 and none found
SDC will complete staff education that electric portable heaters are prohibitive at the facility.
Maintenance director will complete monthly audit of offices and resident room for electric space heaters
Maintenance director will present result of electrical space heaters audit findings at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved
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 ensure electrical equipment was secured against unauthorized use, affecting two of fourteen smoke zones within the facility. Refer to NFPA 99. 6.3.2.1

Findings include:

1. Observations made on April 8, 2019, between 12:00 pm and 1:30 pm, revealed unlocked electrical panels in the following locations:

a. 12:00 pm, 2nd floor, in the corridor, near the smoke barrier doors, by the nurse station between room 202 -203;
b. 1:40 pm, 1st floor, in the corridor near the adminstrator's office.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the unlocked electrical panels in the above named locations.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Maintenance director locked electrical panel on 2nd floor, in the corridor, near the smoke barrier doors, by the nurse's station between room 202-203, and 1st floor, in the corridor near the administrator office.
An audit of electrical panels was completed by Maintenance director on 4/9/19 and no other panels were found to be unlocked.
Maintenance director/designee will complete inspection of electrical panel doors weekly for 2 weeks and then monthly to ensure that all electrical panel doors are locked
The maintenance director will present electrical panel door inspection results at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved
NFPA 101 STANDARD Electrical Systems - Receptacles: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 - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on documentation review and interview, it was determined the facility failed to maintain protection of electrical receptacles and perform required inspection/testing, affecting 240 of 240 resident bed locations within the facility.

Findings include:

1. Document review on April 8, 2019, at 8:00 am, revealed electrical receptacles at resident bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the facility could not provide documentation that receptacles at resident bed locations were tested.


2. Observation made on April 8, 2019, at 1:35 pm, inside the 1st floor PT Area, revealed there was a hydrocollator plugged into a non-GFI receptacle.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed there was a hydrocollator plugged into a non-GFI receptacle.


3. Observation made on April 8, 2019, at 1:38 pm, 1st floor, revealed near the entry door to the PT area, inside the room there was a loose duplex wall receptacle.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed there was a loose duplex wall receptacle.








 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
Receptacle testing of all receptacles was completed by Maintenance staff on 4/12/19
Receptacle for Hydrocollator in PT area was changed to GFI receptacle on 4/9/2019 by maintenance staff
The loose duplex wall receptacle by PT entry door was repaired on 4/8/19 by maintenance staff
Maintenance director/designee completed audit of receptacles for GFI and repair on 4/19/19 an d no issue was identified
Maintenance director or designee will complete inspection of 20 rooms receptacles weekly for 2 weeks and then monthly to identify receptacles that may need repair
Maintenance director present receptacles audit report findings monthly QAPI meeting comprising of interdisciplinary team until substantial compliance is achieved .

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 document review and interview, it was determined the facility failed to ensure the emergency back-up generator was tested at required intervals, affecting 11 of twelve inspections.

Findings include:

1. Document review on April 8, 2019, at 8:00 am, revealed for the previous 12 months, the facility could only provide documentation the emergency generator was exercised under load for 30 minutes.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed the generator exercising documentation was not available.






 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
All missing monthly generator full load test for 2018/2019 have been located and placed in generator binder
NHA will re-educate Maintenance staff about scheduling as well as collecting report from generator testing provider. Re-education will be completed by 4/30/19
Maintenance director will audit Generator testing binder for full load testing documentation by service provider monthly. Monthly report not found at the time of audit will be corrected at the time
Maintenance director will present generator full load testing documentation audit results at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were properly stored, affecting 1 of 5 levels within the facility.

Findings include:

1. Observation made on April 8, 2019, at 1:52 pm, revealed there were 8 freestanding E-type portable oxygen cylinders inside the basement oxygen storage room.

Interview at the exit conference with the Administrator and the Maintenance Director on April 8, 2019, at 2:35 pm, confirmed there were 8 freestanding E-type portable oxygen cylinders.




 Plan of Correction - To be completed: 05/13/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements
The 8 oxygen tanks were immediately removed and stored in oxygen tank holder on 4/8/2019
Maintenance completed audit of oxygen rooms on 4/9/19 for unsecured oxygen and all oxygen tanks secured in oxygen holders.
Maintenance will complete audit of the oxygen storage rooms weekly for 2 weeks and monthly for 3 months to ensure that oxygen are stored and secured properly in oxygen rooms
The maintenance director will present hazardous oxygen rooms audit results at monthly QAPI comprising of interdisciplinary team until substantial compliance is achieved

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