Pennsylvania Department of Health
FAIRVIEW NURSING AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FAIRVIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  36 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.
FAIRVIEW NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 29, 2024, it was determined that Fairview Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.








 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

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

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview it was determined that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated at least annually, for one of one plan.

Findings include:

Document review on January 29, 2024, at 10:00 a.m., revealed the facility failed to update local resources, and key personnel on its succession plan during the annual review of the Emergency Preparedness Plan.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the incomplete annual update.









 Plan of Correction - To be completed: 03/15/2024

1. The facility updated the local resources, and key personnel of the Emergency Preparedness Plan.
2. The Maintenace Director/Designee will complete routine audits to ensure the Emergency Preparedness Plan is updated with current information.
3. Maintenance Director/Designee will educate the staff on the requirements of ensuring that the Emergency Preparedness Plan is updated and current.
4. The Maintenance Director/Designee will complete monthly audits x 3 months to ensure the local resources, and key personnel of the Emergency Preparedness Plan is updated and will be reviewed for the QAPI committee.

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


Facility ID# 320402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2024, it was determined that Fairview Nursing and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, that is fully sprinklered.





 Plan of Correction:


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

Based on observation and interview, it was determined the facility failed to maintain carbon monoxide alarms in close proximity to fossil fuel-burning devices, in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting one of three floors.

Findings Include:

Observation on January 29, 2024, at 10:20 a.m., revealed the carbon monoxide alarm in the boiler room was not audible above ambient noise and could not be heard to alert staff outside the room.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the carbon monoxide detectors were not audible.




 Plan of Correction - To be completed: 03/15/2024

1. The carbon monoxide alarm in the boiler room is audible and above ambient noise and can be heard to alert staff outside the room.
2. The Maintenace Director/Designee will complete random testing for the carbon monoxide alarm in the boiler room to ensure it can be heard to alert staff.
3. The Maintenance Director/Designee will educate the maintenance staff on the requirement of ensuring the cardon monoxide alarm is functioning properly.
4. The Maintenance Director/Designee will complete monthly audits x 3 months testing the carbon monoxide alarm in the boiler room to ensure it can be heard to alert staff. Results will be reviewed for the QAPI committee.

NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the building separation, affecting one of three floors.

Findings include:

Observation on January 29, 2024, at 10:30 a.m., revealed, on the third floor, the #3 fire door separating the skilled nursing facility from the original building failed to latch when tested.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the common wall door deficiency.





 Plan of Correction - To be completed: 03/15/2024

1. On the third floor, the number 3 fire door separating the skilled nursing facility from the original building is repaired and functioning properly to the latch.
2. The Maintenace Director/Designee will complete an in-house audit on all floors to ensure proper functioning to latch.
3. The Maintenace Director/ Designee will educate all staff on the requirement for ensuring the fire doors are functioning properly to latch and place in Tels for malfunctioning.
4. The Maintenance Director/Designee will complete monthly audits x 3 months on all floors to ensure fire doors are functioning properly to latch. Results will be reviewed for the QAPI committee.

NFPA 101 STANDARD Means of Egress Requirements - 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.
Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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.
18.2, 19.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200

Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of three levels.

Findings include:

Observation on January 29, 2024, at 10:10 a.m., revealed, the second floor door leading to an enclosed rooftop patio could be mistaken for an exit and lacked signage indicating " Not an Exit. "

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the missing signage.

Refer to NFPA 101.19.2.10.1





 Plan of Correction - To be completed: 03/15/2024


1. The second-floor door leading to an enclosed rooftop patio has signage to indicate it as
" Not an Exit. "
2. The Maintenance Director/ Designee will complete random inhouse audits to ensure that the signage to indicate it is "Not an Exit." Is in place.
3. The Maintenace Director/ Designee will educate maintenance staff on the requirement for ensuring the proper signage to indicate it is "Not an Exit."
4. The Maintenance Director/Designee will complete monthly audits x 3 months on all floors to ensure required signage to indicate it is" Not an Exit. " Results will be reviewed with the QAPI committee.

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 upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of three levels.

Findings include:

Observation on January 29, 2024, at 10:55 a.m., revealed, the second floor corridor by Physical Therapy, a smoke detector was detached from its housing.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the detached smoke detector.





 Plan of Correction - To be completed: 03/15/2024

1. The second-floor corridor by Physical Therapy, the smoke detector detached from its housing was repaired.
2. The Maintenance Director/Designee will complete a random audit on all floors to ensure that the smoke detectors are attached to the house.
3. The Maintenance Director/Designee will educate the maintenance staff on the requirements regarding smoke requirements.
4. The Maintenance Director/Designee will complete audits x 3 months on all floors to ensure that the smoke detectors are attached to the house. Results will be reviewed with the QAPI committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain complete automatic sprinkler protection, affecting one of three floors.

Findings Include:

Observation on January 29, 2024, at 10:20 am, revealed, that on the second floor back elevator lobby, suspended ceiling has been removed and the sprinklers have not been reoriented up.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 pm, confirmed incomplete sprinkler coverage.





 Plan of Correction - To be completed: 03/15/2024

1. The second floor back elevator lobby, the suspended ceiling has been reinstalled to ensure a smoke tight ceiling structure with proper orientation of the sprinkler heads.
2. The Maintenace Director/Designee will complete a random audit on all floors to ensure the drop ceiling structures are in place and smoke tight.
3. The Maintenance Director/Designee will educate the maintenance staff on the requirement that sprinklers must be oriented up.
4. The Maintenance Director/Designee will complete audits x 3 months on all floors to ensure that the sprinklers are oriented up. Results will be reviewed by the QAPI committee.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




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

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting two of three levels.

Findings include:

Document review on January 29, 2024, at 9:30 a.m., revealed the October 2020, fire damper inspection report listed multiple dampers as deficient. Evidence of corrective action was unavailable at the time of survey.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 03/15/2024

1. The facility had a licensed vendor make all the repairs to the fire dampers that were identified from the original inspection report.

2. Maintenance Director/Designee will complete an in-house random audit to ensure the dampers are functioning properly.
3. Maintenace Director/Designee will educate the maintenance staff on the requirements to ensure dampers are functioning properly.
4. The Maintenance Director/Designee will complete an in-house audit x 3 months to ensure dampers are functioning properly. Results will be reviewed by the QAPI committee.

NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform three of twelve required fire drills.

Findings include:

Document review on January 29, 2024, at 9:30 a.m., revealed the facility could not provide documentation that a fire drill was conducted for the following:

a. Second quarter, Third shift.
b. Third quarter, Second shift.
c. Fourth quarter, Fourth shift.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 03/15/2024

1. The facility will ensure that the requirements are met according to the regulation providing one fire drill per shift per quarter moving forward.
2. The Maintenace Director/Designee will complete random audits to ensure that fire drills are conducted as required.
3. The Maintenance Director/Designee will educate the maintenance staff on the requirement to ensure that fire drills are conducted according to regulations.
4. The Maintenance Director/Designee will complete in- house monthly audits x 3 to ensure the fire drills are completed according to the requirements. Results will be reviewed with the QAPI committee.

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain designated smoking areas, affecting one of three floors.

Findings include:

Observation on January 29, 2024, at 11:30 a.m., revealed, the designated smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area. The area contained mulch beds.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the smoking area condition.





 Plan of Correction - To be completed: 03/15/2024

1. The designated smoking area is well kept and without cigarette butts on the ground and contains no mulch beds.
2. The Maintenace Director/Designee will complete random audits to ensure that the designated smoking area is well kept and without cigarette butts on the ground and the area contains no mulch beds.
3. The Maintenance Director/Designee will educate staff on the requirement to ensure that the smoking area is without cigarette butts on the ground and the area contains no mulch beds.
4. The Maintenance Director/Designee will complete random audits x 4 weeks to ensure the smoking area is well kept and without cigarette butts on the ground and the area contains no mulch beds.


NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting two of three levels.

Findings include:

Document review on January 29, 2024, at 9:30 a.m., revealed the April 2023, Annual Fire Door Inspection report listed 4- doors as deficient. Evidence of corrective action was not available at time of survey.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the rated door deficiencies.





 Plan of Correction - To be completed: 03/15/2024

1. The facility will replace the four doors that were listed as deficient in the annual fire door inspection report. The facility is requesting a Time Limited Waiver for the door replacements due to manufacture time frame.
2. The Maintenace Director/Designee will complete random audits to ensure annual fire door inspection is completed and reports are available.
3. Maintenance Director/Designee will educate maintenance staff on inspecting fire doors according to regulations.
4. Maintenance Director/Designee will complete random audits to ensure the fire doors are functioning in a safe manner weekly x 4 weeks. The results will be reviewed by the QAPI committee.

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 facility failed to maintain protection of electrical wiring, affecting two of three levels.

Findings include:

Observations on January 29, 2024, revealed the following electrical wiring deficiencies:

a. 10:15 a.m., the third floor laundry by washers, electrical panel missing protective blank.
b. 10:16 a.m., the third floor outside laundry, light switch damaged and missing cover.
c. 10:20 a.m., the third floor boiler room, pump controller box missing its cover.
c. 11:00 a.m., the second floor dining, broken duplex receptacle

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.





 Plan of Correction - To be completed: 03/15/2024

1. The facility has maintained protection of electrical wiring for two of three levels.
a. The third-floor laundry by washers, electrical panel missing protective blank was repaired.
b. The third floor outside laundry, light switch damaged and missing cover was repaired.
c. The third-floor boiler room, pump controller box missing its cover was repaired.
c. The second-floor dining, broken duplex receptacle was repaired.

2. The Maintenance Director/Designee will complete a random audit in-house to ensure electrical panels and outlets have maintained protection.
3. Maintenance Director/ Designee will be educated the maintenance staff on the requirement to maintain protection for electrical panels.
4. Maintenance Director/ Designee will complete random audits x 4 weeks for electrical panels to ensure maintained protection. The results will be reviewed with the QAPI committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of three floors.

Findings include:

Observation on January 29, 2024, at 11:30 a.m., revealed, in the first floor nourishment, an extension cord was powering a large ice machine.

Exit Interview with the Administrator and Property Manager on January 29, 2024, at 12:15 p.m., confirmed the unauthorized electrical device.






 Plan of Correction - To be completed: 03/15/2024

1. The first-floor nourishment/pantry, the extension cord that was powering the ice machine has been removed.
2. Maintenace Director/ Designee will complete random audits in other rooms and offices to check and ensure no extension cords are in use.
3. Maintenance Director/ Designee will educate all staff on the requirement of no extension cords.
4. Maintenance Director/ Designee will complete random audits x 4 weeks for other rooms and offices to ensure no extension cords. Results will be reviewed with the QAPI committee.


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