Nursing Investigation Results -

Pennsylvania Department of Health
PHOEBE WYNCOTE
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PHOEBE WYNCOTE
Inspection Results For:

There are  39 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.
PHOEBE WYNCOTE - 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 29, 2019, it was determined that Phoebe Wyncote had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.






 Plan of Correction:


483.73(b)(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 (EP) plan that included policies and procedures that include subsistence needs for staff and residents during an emergency, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 29, 2019, between 8:30 a.m. and 3:30 p.m., revealed the Emergency Preparedness plan did not include policies and procedures for provisions for subsistence needs for staff and residents, for the following:

a. Temperatures to protect residents health and sanitary storage of provisions;
b. Contact information for pharmaceutical supplies;
c. Sewage and waste disposal.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the EP plan did not include all required provisions to be used in the event of an emergency.




 Plan of Correction - To be completed: 06/28/2019

The Emergency Preparedness plan will be updated to include policies and procedures for provisions for subsistence needs for staff and residents for Temperatures to protect resident's health and sanitary storage of provisions and Sewage and waste disposal. Contact information for pharmaceutical supplies will be added to the Emergency Contact list, which is included in Disaster manuals. The updated plan will be reviewed at the next scheduled QAPI meeting, and at least annually, and monitored by the Administrator.
483.73(b)(4) REQUIREMENT Policies/Procedures for Sheltering in Place: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:]

(4) A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility].

*[For Inpatient Hospices at 418.113(b):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.
Observations:
Name: - Component: -- - Tag: 0022

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan that provides policies and procedures that outline a means of sheltering residents, staff, and volunteers who remain in the facility's care, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 29, 2019, between 8:30 a.m. and 3:30 p.m., revealed the Emergency Preparedness plan did not include policies for how it will provide a means to shelter in place for volunteers, to be reviewed and updated at least annually.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the EP plan did not include a policy for sheltering in place, in the event of an emergency.








 Plan of Correction - To be completed: 06/28/2019

The Emergency Preparedness Plan will be updated to include policies for providing a means to shelter in place volunteers, which will be reviewed and updated at least annually. The updated plan will be reviewed at the next scheduled QAPI meeting and monitored by the Administrator.
483.73(b)(6) REQUIREMENT Policies/Procedures-Volunteers and Staffing: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:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at 403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at 418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Name: - Component: -- - Tag: 0024

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan for the use of volunteers in an emergency or other staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 29, 2019, between 8:30 a.m. and 3:30 p.m., revealed the Emergency Preparedness plan did not include policies for the use of volunteers in an emergency, to be reviewed and updated at least annually.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the EP plan did not include a policy for utilizing volunteers, in the event of an emergency.










 Plan of Correction - To be completed: 06/28/2019

The Emergency Preparedness plan will be updated include policies for the use of volunteers in an emergency, which will be reviewed and updated at least annually. The updated plan will be reviewed at the next scheduled QAPI meeting and monitored by the Administrator.
483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(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 (EP) plan with policies and procedures to maintain the Essential Electrical System operational for the duration of emergencies, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 29, 2019, between 8:30 a.m. and 3:30 p.m., revealed the Emergency Preparedness plan did not include policies and procedures to have emergency power systems, or plans in place, to maintain safe operations while sheltering in place, including onsite fuel source.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the EP plan did not include a means of maintaining emergency power systems, in the event of an emergency.






 Plan of Correction - To be completed: 06/28/2019

The Emergency Preparedness plan will be updated to include policies and procedures to include an updated letter from our generator fuel provider to support the onsite fuel source. This will be reviewed and updated at least annually. The updated plan will be reviewed at the next scheduled QAPI meeting and monitored by the Administrator.
Initial comments:Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0000


Facility ID# 232102
Component 02
Cassell Hall and Berger Hall

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2019, it was determined that Phoebe Wyncote - Cassell Hall and Berger Hall 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 483.70(a).

This is a two-story, Type V (000), unprotected wood frame structure, with a basement and an attic, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Contiguous Non-Health:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Multiple Occupancies - Contiguous Non-Health Care Occupancies
Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.4.1, 19.1.3.4.1
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0132

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating at common fire wall separations from non-health care facilities, affecting 1 of three building separations.

Findings Include:

1. Observation made on April 29, 2019, between 1:00 p.m. and 2:00 p.m., revealed the fire door separating the large storage area and the non health care building did not positively latch into its frame, basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the fire separation was not maintained.









 Plan of Correction - To be completed: 06/28/2019

 The maintenance director will work with a locksmith to reset the fire-rated hinges on the door separating the storage area from the non-health care area. Properly setting the fire-rated hinges will allow the door to close and seal.
In addition, the maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. Both the corrective action and inspections will be completed by June 28th, 2019. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed for the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.


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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.

Findings include:

1. Observation made and documentation reviewed on April 29, 2019, between 8:30 a.m. and 3:30 p.m., revealed the facility has been classified as a two-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered. The building exceeds the maximum allowable story height for this type of construction by one story.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the building construction type.













 Plan of Correction - To be completed: 06/28/2019

Phoebe Wyncote requests this deficiency be part of the Department of Health provided FSES, as the building height cannot be altered.
NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0211

Based on observation, document review and interview, it was determined the facility failed to maintain the minimum headroom clearance and unobstructed means of egress, in three instances, affecting 2 of three levels within the facility.

Findings include:

1. Observation made and documentation reviewed on April 29, 2019, between 8:30 a.m. and 3:30 p.m., revealed the headroom clearance within the corridors of the basement, near the maintenance office and staff areas, measured at six feet at the ramp leading to the laundry, which was less than the minimum height requirement of six feet-eight inches.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the basement headroom clearance.


2. Observation made on April 29, 2019, between 1:00 p.m. and 2:00 p.m., revealed the exit door to the exterior of the building had missing hardware, basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed exit discharge door hardware was not installed.


3. Observation made on April 29, 2019, between 1:00 p.m. to 3:30 p.m., revealed there were dead bolts installed on both swinging exit doors from the kitchen, leading through the dining room, which would impede egress when engaged, 1st floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed there were impediments to exiting.
















 Plan of Correction - To be completed: 06/28/2019

Phoebe Wyncote requests this deficiency be part of the Department of Health provided FSES as the ceiling height cannot be altered.
The maintenance director will work with a locksmith to replace the stairwell exit door hardware with fire-rated locking exit/panic hardware.
The maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
3. The maintenance director will work with a locksmith to replace the deadbolts on the kitchen doors with fire-rated locking exit/panic hardware. Maintenance staff will conduct a building-wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0281

Based on observation and interview, it was determined the facility failed to maintain continuous illumination of the means of egress, affecting 1 of five exit stairways within the facility.

Findings include:

1. Observation made on April 29, 2019, at 1:05 p.m., revealed exterior exit discharge lighting could be manually activated by a light switch, near the kitchen exit.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed manual intervention controlled egress lighting.













 Plan of Correction - To be completed: 06/28/2019

The light switch controlling the exterior light will be removed so the light can be hardwired and always stay powered. The junction box inside the building will be blanked-out with an electrical plate. The maintenance director will oversee an exterior exit light inspection of the property. If any additional lights are found to be controlled by switches, those switches will be removed, the lights hardwired, and the junction boxes blanked-out. Both of these will be done by June 12th, 2019. Additionally, if any exterior lighting is installed in the future, all lights will be hardwired rather than controlled by switches.
Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.

NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, in three instances, affecting 2 of three levels.

Findings Include:

1. Observation made on April 29, 2019, between 1:00 p.m. and 2:00 p.m., revealed the basement door into the stairwell had hardware missing, basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the corridor doors required positive self-latching adjustment.


2. Observation made on April 29, 2019, at 2:55 p.m., revealed the stair tower corridor double doors across from room 415 did not positively latch into their frame, 2nd floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the corridor doors required positive self-latching adjustment.


3. Observation made on April 29, 2019, at 3:20 p.m., revealed the dumbwaiter access door, inside the Sunshine dining room, lacked self-closing hardware, 2nd floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the vertical opening required fire rated components.









 Plan of Correction - To be completed: 06/28/2019

1. The maintenance director will work with a locksmith to install a new fire-rated latch on the existing basement doorframe so the fire-rated panic hardware can properly seal the stair tower.
In addition, the maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. Both the corrective action and inspections will be completed by June 28, 2019. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected within 30 days of the deficiency. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
2. The maintenance director will work with a locksmith to replace the hardware on the stair tower corridor double doors across from room 415 with fire-rated locking exit/panic hardware to ensure that they positively latch into the frame.
In addition, the maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. Both the corrective action and inspections will be completed by June 28, 2019. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected within 30 days of the deficiency. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
3. The maintenance director will work with a locksmith to install self-latching fire-rated hardware on the dumbwaiter access door in the second floor dining room.
In addition, the maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. Both the corrective action and inspections will be completed by June 28, 2019. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected within 30 days of the deficiency. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.

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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas with smoke tight separations, in sprinklered locations, affecting 1 of three levels.

Findings Include:

1. Observations made on April 29, 2019, between 1:00 p.m. and 2:00 p.m., revealed the sprinkler/oxygen storage area corridor door did not positively latch into the frame, basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the hazardous area required smoke tight separation.

























 Plan of Correction - To be completed: 06/28/2019

The maintenance director will work with a locksmith to repair or replace the fire-rated door hardware connecting the laundry area and the sprinkler/oxygen storage area.
In addition, the maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. Both the corrective action and inspections will be completed by June 30th, 2019. These inspections will be annual. Any deficiencies found during subsequent annual inspections will be corrected within 30 days of the deficiency. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.

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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain identification of kitchen equipment, affecting 1 of three levels.

Findings Include:

1. Observation made on April 29, 2019, between 1:15 p.m. and 2:30 p.m., revealed
the kitchen type K fire extinguisher located inside the kitchen, lacked a placard conspicuously placed near the extinguisher stating the fire protection system shall be activated prior to using the fire extinguisher.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed fire extinguisher was not properly identified.






 Plan of Correction - To be completed: 06/28/2019

The maintenance director will order signage for the Type K extinguisher located in the kitchen that states to use the extinguisher in the case of an appliance fire only after the fire suppression system had been activated. This is the only Type K extinguisher in the building so it is the only sign needed. The maintenance director will train and document the dining staff on the proper procedure on when to use this extinguisher.
Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.

NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain complete automatic sprinkler protection, within a fully sprinklered building, in one instance, affecting 1 of five smoke compartments.

Findings Include:

1. Observation made on April 29th, 2019, between 8:30 a.m. and 3:30 p.m., revealed the closet inside the dining area lacked sprinkler installation, 1st floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 pm, confirmed the facility required additional sprinkler coverage.






 Plan of Correction - To be completed: 06/28/2019

The maintenance director has contacted our Sprinkler/Fire Monitoring system service provider to evaluate the spray pattern of the sprinkler heads closest to the closet in the dining room. If the spray pattern is capable of reaching into the closest without the doors in place, then the maintenance director will permanently remove the doors. If the spray pattern of the sprinkler heads is not sufficient to reach into the space, then the Service Provider will install a new sprinkler head in the closet. In addition, the maintenance director will conduct an audit of all space types in the building to ensure there are no spaces without a sprinkler head. If any additional spaces are found, necessary changes to the sprinkler system will be made. The audit and work plan for any changes will be completed by June 30, 2019. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinklers without obstructions, in one instance, affecting 1 of three levels.

Findings Include:

1. Observation made on April 29, 2019, at 2:17 p.m., revealed obstructions to the automatic sprinkler in the basement storage supply room. Items were stored within 18 inches of the sprinkler head.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the obstruction to the automatic sprinkler located in basement supply room.







 Plan of Correction - To be completed: 06/28/2019

The maintenance director will remove the items in the basement storage so there is an 18 inch clearance to the ceiling. Additionally, the maintenance director will oversee a building wide inspection of all storage spaces and shelving to ensure items are not stored within 18 inches of the ceiling. All storage spaces will have designated marks along the wall and signage stating not to place items with 18 inches of the ceiling. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain required inspections and clearances of fire extinguishers, in two instances, affecting 1 of three levels.

Findings Include:

1. Observations made on April 29, 2019, between 1:15 p.m. and 2:30 p.m., revealed fire extinguisher deficiencies at the following locations:

a. Basement medical supply storage room fire extinguisher, monthly quick check inspection was not documented on the inspection tag;
b. Basement medical supply storage room fire extinguisher was not conspicuous. The extinguisher was obstructed by boxes.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed fire extinguishers were not maintained as required.





 Plan of Correction - To be completed: 06/28/2019

The maintenance director will train the maintenance staff on proper monthly fire extinguisher inspections. During monthly fire extinguisher checks, a member of the maintenance staff will use a map and checklist to ensure all building extinguishers are checked and within proper working parameters. Additionally, staff will be instructed to leave access to fire extinguishers open and clear of items. The maintenance staff will also be inspecting for proper access during monthly inspections. If items are found to block an extinguisher, the maintenance director will retrain the staff responsible for placing those items in the path of the extinguisher. The items blocking the extinguisher in the medical supply room were moved and the extinguisher quick check inspection completed on May 15th, 2019. Any deficiencies found during subsequent monthly inspections will be corrected immediately. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with positive self-latching into their frames, in four instances, affecting 1 of three levels.

Findings Include:

1. Observations made on April 29, 2019, between 1:00 pm and 3:19 pm, revealed the following corridor doors did not positively latch into their frames:

a. Door to room 307 failed to securely latch when closed, 2nd floor;

b. Resident room corridor doors 301, 302, 305, 309 and 317, the inactive leaves have manual flush bolts installed in lieu of positive self-latching hardware, 2nd floor;

c. Resident room corridor door inactive leaves along the 400 wing, the inactive leaves hae manual flush bolts installed in lieu of self-latch hardware, 2nd floor;

d. Resident room 408 corridor double doors were closed but did not positively latch into its frame. The inactive leaf had a manual flush bolt in lieu of automatic self-latching hardware installed, 2nd floor.

Interview at the exit conference with the Administrator and the Director of Maintenance, on April 29, 2019, at 3:30 pm, confirmed the corridor doors required positive self-latching hardware at the above named locations.




















 Plan of Correction - To be completed: 06/28/2019

The maintenance director will work with a locksmith to repair or replace the fire-rated door hardware to ensure the corridor door to 307 properly closes and latches securely.
The maintenance director will work with locksmith,to replace all manual flush bolts in rooms 301, 302, 305, 309, and 317, with fire-rated self-latching hardware to ensure the corridor doors for all stated rooms properly close and latch securely.
The maintenance director will work with a locksmith to install self-latching fire-rated hardware on all resident room secondary leaf corridor doors in the 400 wing.
In addition, the maintenance director and maintenance staff will be conducting a building wide door inspection using the ASHE Checklist for Fire Door Assembly Inspection sheet. These inspections will be annual. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.

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 Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain Essential Electrical System components, affecting the entire facility.

Findings Include:

1. Observation made on April 29, 2019, at 2:30 p.m., revealed the emergency generator remote annunciator panel, located across from the 2nd floor nurse station, visual derangement Communication signal was flashing red.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the generator panel had an alarm condition.







 Plan of Correction - To be completed: 06/28/2019

The maintenance director will work with the generator service company to investigate the cause for the annunciator panel being activate. In the future, during the generator service company's monthly generator inspections, the technician assigned to complete the inspection will also look at the annunciator to ensure the panel is properly working. Any deficiencies found during subsequent monthly inspections will be corrected. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.
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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to store gas equipment as required, affecting 1 of five smoke compartments.

Findings Include:

1. Observation made on April 29, 2019, at 1:48 p.m., revealed H size oxygen cylinders were stored near combustible materials (boxes), in the basement storage area.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on April 29, 2019, at 3:30 p.m., confirmed the improper storage of gas equipment.





 Plan of Correction - To be completed: 06/28/2019

Combustible items were removed from the area and there will be no other items stored in the enclosed area. The maintenance director will contract Life Safety Building Planning to ask for a building use change on storing the oxygen cylinders. Currently, oxygen cylinders are stored in the basement. In the future, oxygen cylinders will be stored outside in an enclosed and locked area along the back of the building. Once the use of the building changes are approved, the maintenance director will audit the basement to ensure there are no remaining cylinders stored within unapproved areas. Results of audits will be monitored by reviewing, discussing, and providing interventions as needed at the next two Quarterly QAPI Meetings. The audit results, and any interventions will be monitored by the NHA.

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