Nursing Investigation Results -

Pennsylvania Department of Health
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are  32 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.
RENAISSANCE HEALTHCARE & 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 February 14, 2019, it was determined that Renaissance Healthcare & Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.


 Plan of Correction:


483.73(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 plan, affecting the entire component.

Findings Include:

1. Documentation reviewed on February 14, 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 February 14, 2019, at 2:35 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 03/31/2019

An 1135 waiver has been created and implemented for the Emergency Preparedness Plan (EPP). The documents will be placed in the EPP binder.
The Maintenance Director or Designee will review the 1135 waiver annually and update as needed.
Maintenance or Designee will review the 1135 waiver with the Administrator annually and present any changes to the QAPI committee for further recommendations if needed.

483.73(c)(1) REQUIREMENT Names and Contact Information: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.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness communication plan that contained all the required contact information, affecting the entire component.

Findings include:

1. Review of documentation on February 14, 2019, at 8:00 am, revealed the facility did not have an an Emergency Preparedness Communication plan that included contact information for the following:
a. Patients' physicians
b. Other long term care facilities.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/31/2019

A Mutual Aide Agreement (MAA) was developed and implemented as part of the EPP which includes other Long-Term Care Facilities. A list of the contact information was created that includes the Resident Physician Contact Information and Contact Information for the facilities listed in the MAA.
Maintenance Director or Designee will review the MAA and Contact information quarterly and update as needed.
Maintenance or Designee will review the MAA and Contact annually with the Administrator and present any changes to the QAPI committee for further recommendations if needed.

483.73(c)(2) REQUIREMENT Emergency Officials Contact Information: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.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at 483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, or local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at 483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.
Observations:
Name: - Component: -- - Tag: 0031


Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan that included a communication plan containing all required contact information, affecting the entire component.

Findings include:

1. Review of documentation on February 14, 2019, at 8:00 am, revealed the facility did not have an an Emergency Preparedness plan that included a Communication plan that contained Emergency Officials Contact Information for all of the following:

a. Federal, State, tribal, regional, or local emergency preparedness staff;
b. The State Licensing and Certification Agency;
c. The Office of the State Long-Term Care Ombudsman;
d. Other sources of assistance.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/31/2019

Contact information for Federal, State, City, DOH, Ombudsman, State Police, Local Police, Fire Department, and Local Utility Companies was created and placed in the EPP.
Maintenance Director or Designee will review the contact list semi-annually and update as needed.
Maintenance Director or Designee will review the contact list with the Administrator annually and present changes to the QAPI committee for further recommendations if needed.

483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan that included a means of providing information about the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting the entire component.

Findings include:

1. Document review on February 14, 2019, at 8:00 am, revealed the facility lacked an Emergency Preparedness plan that included a means of providing information about the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/31/2019

A Mutual Aide Agreement (MAA) was developed and implemented as part of the EPP which includes other Health Care Facilities to assist in an Emergency and provides information about facility's needs and the ability to provide assistance to the Philadelphia South Zone Emergency Coalition.
Maintenance Director or Designee will begin attending meetings for the Philadelphia South Zone Emergency Coalition (PSZEC) and review the MAA on an annual basis and update as needed.
Maintenance Director or designee will report updates from (PSZEC) meetings to Administrator and QAPI and make changes as needed.

483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with 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.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives, affecting the entire component.

Findings include:

1. Document review on February 14, 2019, at 8:00 am, revealed the facility lacked a written Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.
Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the documentation was unavailable.



 Plan of Correction - To be completed: 03/31/2019

The admission packet was updated to inform families and residents about the facility's EPP.
Maintenance Director or designee will review policies and procedures to inform families, Resident representatives, and residents regarding the EPP on an annual basis and update as needed.
Maintenance Director or designee will review policies and procedures to inform families, Resident representatives, and residents regarding the EPP annually with the Administrator and present changes to the QAPI committee for further recommendations if needed.

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 plan to include a plan to ensure the emergency generator provides continuous power during an emergency, affecting the entire component.

Findings include:

1. Document review on February 14, 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 February 14, 2019, at 2:35 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/31/2019

Cardinal Fuel was contracted to provide alternate fuel if the primary fuel company, Royal Petroleum, cannot provide fuel in an emergency. The EPP was updated and contains the agreements for both the primary and secondary fuel company Cardinal Fuel and Royal Petroleum.
Maintenance Director or Designee will contact fuel companies annually to ensure fuel will be provided in an emergency.
Maintenance Director or Designee will contact fuel companies annually to ensure fuel will be provided in an emergency and review with the Administrator and make changes as needed. Any changes will be presented to the QAPI committee for further recommendations if needed.

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


Facility ID# 420302
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2019, it was determined that Renaissance Healthcare & 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 two-story, Type II (222), fire resistive construction, 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 and interview, it was determined the facility failed to ensure carbon monoxide detectors were installed in accordance with the "Care Facility Carbon Monoxide Alarms Standard Act " affecting the entire component.

Findings Include:

1. Observation made on February 14, 2019 at 1:35 pm, revealed the single independent battery operated carbon monoxide alarm devices located inside the basement laundry room and the boiler room were installed where they may not be heard by staff on duty in other areas of the component.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the carbon monoxide alarm devices were installed where they may not be heard by staff on duty in other areas of the component.




 Plan of Correction - To be completed: 03/31/2019

Plans for installation of Carbon Monoxide Detectors have been submitted to Dept of Health Plan Review Tracking # 35531.
Carbon Monoxide Detectors will be installed once approved inside the basement laundry room and boiler room and will be tied into the fire alarm system which will alert the monitoring system and staff in the event of Carbon Monoxide Detection.
Maintenance Director or designee will ensure fire alarm and detectors is inspected semi-annually by fire alarm company to ensure proper function and repair/replace as needed.
Maintenance Director or designee will review inspection findings with Administrator semi-annually and report findings to QAPI committee for further recommendations if needed.

NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction's fire resistive rating, affecting 2 of 7 smoke zones within the component.

Findings include:

1. Observations made on February 14, 2019 between 12:57 pm and 1:45 pm, revealed broken or incomplete rated ceiling assembly light bonnets in the following locations:

a. 12:57 am, 1st floor, above the suspended ceiling, resident room # 107.
b. 1:45 pm, basement, in the corridor above the suspended ceiling in front of the elevator.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the broken or incomplete rated ceiling assembly light bonnets in the above named locations.






 Plan of Correction - To be completed: 03/31/2019

The bonnets on 1st floor, above the suspended ceiling, resident room # 107 and basement, in the corridor above the suspended ceiling in front of the elevator was replaced immediately.
Maintenance Director or designee will complete maintenance rounds periodically and replace/repair bonnets as needed.
Maintenance Director or designee will report findings of periodic rounds with the Administrator.. Findings will be reviewed by the QAPI committee for further recommendations.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




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

Based on observation and interview, it was determined the facility failed to ensure that prohibited items were not being stored in rated exit stairway enclosures, affecting 1 of 3 exit stairways within the component.

Findings include:

1. Observation made on February 14, 2019 at 1:23 pm, revealed inside the 2nd floor exit stairway near resident room # 227, a bundle of rags was being stored.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the bundle of rags was being stored in the exit stairway.






 Plan of Correction - To be completed: 03/31/2019

The rags inside the 2nd floor exit stairway near room #227 were removed immediately.
Maintenance Director or Designee will inspect exit stairways periodically to ensure that there is no debris within them.
Maintenance Director or designee will report findings of periodic inspections to the Administrator and the QAPI committee.

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 rated doors to hazardous areas, affecting 1 of 7 smoke zones within the facility.

Findings include:

1. Observation made on February 14, 2019 at 1:30 pm, basement, revealed the rated corridor door to the main laundry room had several holes around the door knob.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the door had several holes around the door knob.






 Plan of Correction - To be completed: 03/31/2019


The door to the main laundry room had steel bolts installed that completely sealed and filled the holes in the door.
Maintenance Director or designee will inspect doors annually during annual door audit and repair/replace as needed.
Maintenance Director will review findings of the annual door audit with Administrator and QAPI committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview it was determined the facility failed to maintain automatic sprinkler system components, affecting 3 of 7 smoke zones within the facility.

Findings include:

1. Observations made on February 14, 2019 between 12:26 pm and 1:02 pm, revealed sprinklers that were recessed above the ceiling, which would obstruct the spray pattern of the sprinkler, in the following locations:

a. 12:26 pm, 2nd floor, inside the spa room that is located across from resident room # 216
b. 1:02 pm, 1st floor, inside the spa room that is located across from the unit manager's office.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the recessed sprinklers in the above named locations.

2. Observations made on February 14, 2019 between 1:36 pm and 1:40 pm, revealed sprinklers with debris on them in the following locations:

a. 1:36 pm, basement main laundry room, two sprinklers above the washers and dryers.
b. 1:40 pm, basement, inside personal laundry room # B-13.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the sprinklers with debris in the above named locations.

3. Observation made on February 14, 2019 at 2:15 pm, revealed inside the sprinkler riser room, the sprinkler gauge was over 5 years old, dated 2013.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the sprinkler gauge was over 5 years old, dated 2013.





 Plan of Correction - To be completed: 03/31/2019

Recessed Sprinkler heads in the ceiling located 2nd floor, inside spa room across room 216, 1st floor, inside spa across from unit manager's office were repaired to allow for proper function and no longer recessed.
Sprinkler Heads with debris on them located in basement main laundry above washer and dryer, basement inside personal laundry were cleaned to remove debris.
Sprinkler gauge inside sprinkler riser room was replaced by Sprinkler Inspection company.
Maintenance Director or designee will inspect sprinkler heads quarterly during quarterly sprinkler inspections by Sprinkler Inspection Company. Maintenance Director or designee will inspect Sprinkler gauge on sprinkler risers annually during annual sprinkler test.
Maintenance Director or designee will review findings of quarterly sprinkler inspections and annual sprinkler test with Administrator and QAPI committee for further recommendations if needed.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier partitions, affecting 3 of 7 smoke zones within the component.

Findings include:

1. Observations made on February 14, 2019 between 12:20 pm and 12:45 pm revealed penetrations in smoke barrier walls had been sealed with an unknown yellow expanding spray foam material in the following locations:

a. 12:20 pm, 2nd floor, above the suspended ceiling, inside resident room # 216.
b. 12:45 pm, 2nd floor, above the suspended ceiling, inside resident room # 205.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed smoke barrier wall penetrations had been sealed with an unknown spray foam material in the above named locations.



 Plan of Correction - To be completed: 03/31/2019

Yellow foam was removed from 2nd floor above suspended ceiling inside room 216 and from 2nd floor above suspended ceiling inside room 205 and filled penetrations with (3M CP25W+; UL: WL1296).
Maintenance Director or designee will complete maintenance rounds periodically and remove yellow foam and fill penetrations with (3M CP25W+; UL: WL1296) as needed.
Maintenance Director or designee will report findings of periodic rounds with the Administrator. Findings will be reviewed by the QAPI committee for further recommendations.

NFPA 101 STANDARD HVAC: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.
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 fire dampers, affecting the entire component.

Findings include:

1. Document review on February 14, 2019 at 8:00 am, revealed the fire damper inspection and exercise report dated January 21, 2019, indicated that 17 of the facility's fire dampers had failed inspection and exercise testing and had not been repaired as of the Life Safety Inspection survey date of February 14, 2019.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the failed dampers had not been repaired.








 Plan of Correction - To be completed: 03/31/2019

17 of the failed dampers have been repaired and re-inspected and are functioning properly.
Maintenance Director or designee will have dampers inspected and tested every four years during 4 year damper inspection and test and repair/replace dampers as needed.
Maintenance Director or designee will review findings with Administrator and QAPI committee for further recommendations if needed.

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0754


Based on observation and interview, it was determined the facility failed to properly store soiled linens greater than an aggregate amount of 32-gallons in a protected hazardous storage area, affecting 1 of 7 smoke zones within the component.

Findings include:

1. Observation on February 14, 2019, at 12:25 pm, revealed two filled 32 gallon soiled linen containers with a combined capacity of approximately 64 gallons, were being stored inside the 2nd floor spa room.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the soiled linen containers were being stored inside the 2nd floor spa room.





 Plan of Correction - To be completed: 03/31/2019


Soiled utility cart was removed from 2nd floor spa room immediately and placed in the soiled utility room.
Housekeeping director or designee will inspect shower rooms daily to remove soiled utility carts from shower rooms and are placed in the soiled utility room.
Housekeeping director or designee will make periodic rounds to ensure that soiled utility carts are not present in the shower rooms and are placed in the soiled utility room. Findings will be submitted to the QAPI committee for further recommendations if needed.

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 that electrical wiring was protected, affecting 2 of 3 levels within the component. Installation shall be in accordance with NFPA 99 Section 6.3.2.1

Findings include:

1. Observations made on February 14, 2019, between 12:14 pm and 1:15 pm, revealed unprotected electrical wiring in the following locations:

a. 12:14 pm, 2nd floor, in the corridor near resident room # 219, above the ceiling, wires were spliced together with wire nuts only and not in a secured junction box.
b. 12:50 pm, 2nd floor, in the corridor near resident room # 214, above the ceiling, wires were spliced together with wire nuts only and not in a secured junction box.
c. 12:55 pm, 1st floor, in the corridor near resident room # 114, above the ceiling, wires were spliced together with wire nuts only and not in a secured junction box.
d. 1:15 pm, 1st floor, in the corridor near resident room # 127, above the ceiling, an open junction box with exposed wiring.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the unprotected electrical wiring in the above named locations.




 Plan of Correction - To be completed: 03/31/2019

Exposed wiring was secured inside of a junction box which was secured to a wall in the following areas: near room 219 above ceiling, near 214 above ceiling, near 114 above ceiling, near 127 above ceiling.
Maintenance Director or designee will complete maintenance rounds periodically and secure exposed wiring to a junction box on the wall as needed.
Maintenance Director or designee will report findings of periodic rounds with the Administrator. Findings will be reviewed by the QAPI committee for further recommendations.

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 maintain the emergency generator, affecting the entire component.

Findings include:

1. Document review on February 14, 2019 at 8:00 am, revealed the facility could not provide documentation that a generator 4 hour exercise had been performed within the previous 36 months.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 03/31/2019

The 4 hour generator exercise was completed by Generator Inspection/Repair Company.
Maintenance Director or designee will have 4 hour generator exercise completed every 3 years during annual generator inspections by Generator Inspection/Repair Company.
Maintenance Director or designee will report any findings to the Administrator and QAPI committee for further recommendations if needed.

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 3 levels within the facility.

Findings include:

1. Observation made on February 14, 2019 at 11:55 am, revealed inside the 1st floor outdoor portable oxygen storage shed, there were 14 freestanding E-type portable oxygen cylinders.

Interview at the exit conference with the Administrator and the Maintenance Director on February 14, 2019, at 2:35 pm, confirmed the portable oxygen cylinders were not properly stored.





 Plan of Correction - To be completed: 03/31/2019

The freestanding portable e-tanks were removed from the 1st floor outdoor storage shed immediately and picked up by the oxygen vendor to be removed from the facility.
Maintenance Director or designee will inspect the outdoor shed once a week to ensure there are no freestanding e-tanks. Any freestanding tanks will be placed in the appropriate bins in the outdoor shed or be picked up and removed from the facility by the oxygen vendor.
Maintenance Director or designee will review findings with the Administrator and QAPI committee for further recommendations if needed.



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