Nursing Investigation Results -

Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  34 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.
VALLEY MANOR REHABILITATION AND HEALTHCARE 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 30, 2019, it was determined that Valley Manor Rehabilitation And Healthcare Center was not in compliance with the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(a)(4) REQUIREMENT Local, State, Tribal Collaboration Process:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the dialysis facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Name: - Component: -- - Tag: 0009

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) program addressing the process for ensuring a coordinated disaster preparedness response, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the Emergency Preparedness plan did not address the process for ensuring cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to ensure an integrated response during an emergency, to be reviewed and updated at least annually.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include collaboration with required entities, in the event of an emergency.


 Plan of Correction - To be completed: 04/09/2019

The Emergency Plan will be updated to ensure cooperation and collaboration with officials.

The EP will be reviewed annually within the facility as well as local officials.

Facility Staff will also be retrained on changes made to the EP.

Corrective Action Date April 16, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

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 January 30, 2019, between 8:30 a.m. and 2:30 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. Staff;
b. Volunteers;
c. Sewage and waste disposal.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, 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: 03/26/2019

The facility will update the Emergency Preparedness plan policy to include provisions for subsistence needs to include staff, volunteers and sewage and waste disposal.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

483.73(b)(2) REQUIREMENT Procedures for Tracking of 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. 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:]

(2) A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at 441.184(b), LTC at 483.73(b), ICF/IIDs at 483.475(b), PACE at 460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at 418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at 485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0018

Based on document review and interview, it was determined the facility failed to develop Policies and Procedures to include tracking of residents and staff during an emergency, as part of the Emergency Preparedness (EP) plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the Emergency Preparedness plan did not include policies and procedures for a means to track on-duty staff in the facility's care during an emergency event and in the event staff and residents are relocated, along with the name and location of the receiving facility or other locations, to be reviewed and updated at least annually.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include a written policy for tracking staff, to be used in the event of an emergency.






 Plan of Correction - To be completed: 03/26/2019

The facility will update the Emergency Preparedness plan to include a policy for tracking staff in the event of an emergency.

Corrective Action Date March 26, 2019.

Facility will audit, review, and update the Emergency plan at least annually. All Results will be reported to and reviewed by the QAPI Committee.

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 that included policies and procedures 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 January 30, 2019, between 8:30 a.m. and 2:30 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.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include a policy for utilizing volunteers, in the event of an emergency.





 Plan of Correction - To be completed: 03/26/2019

The facility will update the Emergency Preparedness plan to include a policy for the use of volunteers in an emergency.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

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 an Emergency Preparedness (EP) plan that included policies and procedures to include the facility's role in providing alternate care at alternate care sites during emergencies, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m, 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, to be reviewed and updated at least annually.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include a policy for the facility's role identified by emergency management officials, in the event of an emergency.








 Plan of Correction - To be completed: 03/26/2019

The facility will update the Emergency Preparedness plan to include providing care and treatment at alternate care sites under an 1135 waiver during a declared emergency.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

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 policies and procedures to include contact information for those individuals and entities outlined within the standard, as part of the Emergency Preparedness (EP) plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m, revealed the Emergency Preparedness communication plan did not include policies and procedures with contact information for the following entities, to be reviewed and updated at least annually.

a. Volunteers.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed contact information was incomplete.



 Plan of Correction - To be completed: 03/26/2019

The facility will update the Emergency Preparedness plan to include a policy and procedure with contact information for volunteers.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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.
[(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 (EP) Communication plan for sharing information on occupancy needs, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the Emergency Preparedness plan did not provide a Communication plan that includes a means of providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction (local and state public health departments, the Incident Command Center, The Emergency Operations Center, or designee), to be reviewed and updated at least annually.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include a communication plan for a means of providing information about their occupancy, in the event of an emergency.






 Plan of Correction - To be completed: 03/26/2019

The facility will update the Emergency Preparedness plan with a communication plan to provide information about the facility occupancy in the event of an emergency.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

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 (EP) Communication plan for sharing emergency preparedness plans and policies with family members, resident representatives, or clients, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the Emergency Preparedness plan did not include a Communication plan demonstrating the method used for sharing information from the emergency preparedness plan with residents, clients or family members.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include a method deemed appropriate for sharing information with families.






 Plan of Correction - To be completed: 03/26/2019

The facility will update the Emergency Preparedness plan to include a method deemed appropriate for sharing information with families.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness testing program to conduct exercises to test the emergency plan, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the Emergency Preparedness plan did not include a full-scale exercise that was community-based or an individual, facility-based exercise to test the emergency plan at least annually.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the EP plan did not include testing of the emergency plan.








 Plan of Correction - To be completed: 04/09/2019

The facility will conduct an individual, facility-based exercise to test the emergency plan.

The facility will meet with the local officials to review and conduct an exercise to test the emergency plan.

This will become a part of QA process to ensure exercise is completed at least annually. Maintenance will monitor and set up annually.

Corrective Action Date April 9, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

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 January 30, 2019, between 8:30 a.m. and 2:30 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.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, 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: 03/26/2019

The facility will update the Emergency Preparedness Plan to include a means of maintaining emergency power systems in the event of an emergency.

Corrective Action Date March 26, 2019.

Facility will audit, review, and amend the Emergency plan as appropriate. All Results will be reported to and reviewed by the QAPI Committee.

Initial comments:Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0000


Facility ID# 480202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification and Complaint survey conducted on January 30, 2019, and February 8, 2019, it was determined that Valley Manor Rehabilitation and Healthcare 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 one story, Type V (000), unprotected wood frame construction, with a basement, which is fully sprinklered.














 Plan of Correction:


NFPA 101 STANDARD Means of Egress Capacity: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.
Means of Egress Capacity
The capacity of required means of egress is in accordance with 7.3.
18.2.3.1, 19.2.3.1
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0231

Based on observation and interview, it was determined the facility failed to maintain the minimum required clearances along the means of egress, affecting 2 of two levels.

Findings Include:

1. Observation on January 30, 2019, between 8:30 am and 2:30 pm, revealed the north east stair tower width was thirty three inches. The required width is thirty six inches.

Interview at the exit conference with the Maintenance Director and Administrator on January 30, 2019, at 2:00 pm, confirmed the stair tower width.


2. Observation made on January 30, 2019, between 8:30 am and 2:30 pm, revealed the basement level lacked acceptable headroom clearance along the exit access corridor. The headroom clearance was less than the required six feet, eight inches, (height was approximately six feet, six inches) from overhead sprinkler piping to finished floor level.

Interview at the exit conference with the Maintenance Director and Administrator on January 30, 2019, at 2:30 pm, confirmed the headroom clearance.





 Plan of Correction - To be completed: 04/09/2019

The facility is requesting that the DOH perform an updated FSES.
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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas with smoke resistant separation from other spaces, in conjunction with sprinkler coverage, affecting 2 of four smoke compartments.

Findings Include:

1. Observation made on January 30, 2019, at 12:49 p.m., revealed the soiled linen room corridor door lacked positive self-latching into the frame when closed, across from room 109.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the hazardous area lacked a smoke resistant separation.

2. Observation made on January 30, 2019, at 1:25 p.m., revealed the basement housekeeping storage room door lacked self-closing hardware.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the hazardous area lacked a smoke resistant separation.





 Plan of Correction - To be completed: 03/26/2019

The soiled utility door across from 109 will be adjusted to have a positive latch.
Self-Closing hardware will be added to the basement housekeeping storage room door.

Corrective Action Date: March 26, 2019

Facility staff will check hazardous storage doors to ensure proper function.

Facility staff will audit hazardous doors weekly x 4 weeks, monthly x3 months, then as deemed necessary by the QAPI committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0345

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

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the April 10, 2018, fire alarm report listed a number of deficiencies, including non-functioning heat detectors,

a. the devices in the crawl space were not inspected/tested;
b. the tamper on the incoming side of the old fire pump is disconnected and needs to be removed;
c. there are multiple tampers on disconnected piping that needs to be removed;

Documentation verifying repairs were made was not available at the time of survey.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed fire alarm system components required repair.



 Plan of Correction - To be completed: 04/09/2019

The devices in the crawl space will be inspected.

The tampers and the piping will be removed from the old fire pump.

Corrective Action Date: April 9, 2019

Facility Staff will audit fire alarm reports to ensure corrective actions are taken. Audits will be conducted monthly or as deemed necessary by the QAPI committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Sprinkler System - Installation: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.
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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0351

Based on documentation review, observation and interview, it was determined the facility failed to submit plans, obtain required layout approvals, perform acceptance testing, and obtain an inspection and approval from the authority having jurisdiction after the completion of the water supply installation and sprinkler system fire pump in accordance with NFPA 13 and NFPA 22 affecting the entire facility.

Findings include:

1. Observation and documentation reviewed on January 30, 2019, and February 8, 2019, between 8:30 a.m. and 3:30 p.m., revealed the facility failed to secure plan approval by the Department of Health (Department) prior to initiating installation of a stand alone fire pump enclosure and new diesel fire pump assembly.

This is a Repeat Deficiency from the February 27, 2018, Division of Safety Inspection survey.

Exit Interview with the Facility Administrator on January 30, 2019, and February 8, 2019, confirmed the facility failed to obtain Department-approved plans prior to initiating alterations and renovations.

28 Pa Code 51.3. Notification (d)

2. Review of documentation, observation and interview with Administration and Maintenance on February 8, 2019, between 1:00 PM and 1:40 PM revealed the water supply for the building automatic sprinkler system was changed from municipal water to two large storage containers. The system was not installed in accordance with NFPA 13 and NFPA 22.

a) The facility failed to notify the authority having jurisdiction (Department of Health) of the water supply change and obtain approval for the new water containers and piping system.
b) The facility failed to submit plans to the Department of Health for the water containers.
c) The facility failed to provide complete information regarding the tank piping on the tank side of the connection to the sprinkler system to the Department of Health for approval.
d) The facility failed to perform and provide acceptance testing to the Department of Health.
e) The facility failed to obtain an inspection and approval of the new water supply, by the Department of Health prior to placing the system in service.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed the facility failed to install, submit plans, obtain required layout approvals, perform acceptance testing, and obtain an inspection and approval from the authority having jurisdiction after the completion of the water supply installation in accordance with NFPA 13 and NFPA 22.


 Plan of Correction - To be completed: 04/09/2019

The facility will be submitting plans to the department through plan review, plans for the installation of permanent water source for the sprinkler system, either by hook up to municipal water or with the use of permanent water containers. Plans to be submitted to Plan Review for approval will also include the piping system, and tank piping. As part of the submission to Plan Review, once plans are approved, the facility will perform and provide required acceptance testing.

The facility will obtain an inspection by the Department of Health through the online Occupancy Inspection Form scheduling an onsite inspection of the state approved plans.

During this time the facility remains on fire watch.
The facility will follow-up with plan review to ensure plan receipt, and approval of the plans. Verification of plan submission to Harrisburg will be provided to the Norristown field office.
The facility has also requested a TLW for the completion of this project.
NHA will ensure that future projects are not started and completed without submitting plans, and obtaining approval of plans prior to the commencement of such projects that require approval from the department.
Projects will be audited as part of the QAPI process to ensure appropriate reporting/approvals have been obtained.

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

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

Findings include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed sprinkler inspection reports listing the following deficiencies. Verification of corrections were not available at the time of survey:

a. Quarterly Inspection reports dated January 4, 2019, and October 9, 2018:
One 200 F brass sidewall sprinkler needs to be installed in the head box as soon as possible.

b. Fire Pump inspection report dated October 9, 2018:
1) Three caps were missing from the test header at the time of inspection and need to be installed as soon as possible;
2) The fire pump is currently fed by (2) temporary water tanks. The sprinkler contractor is not responsible for filling/maintaining the water levels in the tanks.
Documentation verifying maintenance of water tank levels was not available at the time of survey.

c. Quarterly inspection report dated January 12, 2018:
The sprinkler contractor does not currently inspect or run the fire pump, does not inspect any piping or devices, or flow water through the piping outside the building footprint due to the current tank/fire pump set-up. All valves will be visually inspected until proper installation is completed. Verification of corrective action/repairs was not available at the time of this survey.

d. Quarterly Inspection reports dated April 10, 2018, and January 12, 2018:
1) The old incoming pump tamper was found disconnected at the time of inspection;
2) The water motor gong did not function at the time of inspection and needs to be repaired or replaced as soon as possible;
3) There are multiple tampers on disconnected pipe. The valve needs to be removed as soon as possible;
4) Water was not moved through the system due to the current tank set-up.

2. Observation made on January 30, 2019, at 12:20 pm, revealed linens were stored less than 18 inches from the sprinkler inside the linen closet.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the linen storage.

3. Observation and interview with Administration and Maintenance on February 8, 2019, between 1:00 PM and 1:40 PM revealed that the water storage containers, supplying water to the building sprinkler system, lacked the required testing, maintenance and inspections required by NFPA 25, Section 9.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed the sprinkler system water supply was not tested, inspected and maintained in accordance with NFPA 25.

4. Review of documentation, observation and interview with Administration and Maintenance on February 8, 2019, between 1:00 PM and 1:40 PM revealed that the fire pump, for the building automatic sprinkler system, was not operational at the time of the survey.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed the fire pump was not operational at the time of inspection.


 Plan of Correction - To be completed: 04/09/2019

Sprinklers were installed in the head box including a 200 F brass sidewall head.

The three caps were replaced on the test headers.
Facility will maintain documentation verifying water levels in the tanks. Maintenance will check water levels according to NFPA 25 sect 9.

The facility sprinkler contractor has inspected the fire pump and tagged the valves inside the fire pump house. The facility does have the fire pump under a PM program with a fire pump company.
The facility will have the abandoned piping and the motor gong from the non-functioning fire pump removed along with the tampers.
Linens were relocated to be more than 18 inches from the sprinkler head.

The facility is requesting a Time Limited Waiver for the installation of a permanent water source for the fire pump. During this time, the facility has started fire watches and will remain on fire watch until plans have been approved, inspected and passed the acceptance testing by the department.

Facility has requested a TLW for forwarded to Norristown Field Office.


Facility will audit: sprinkler head box, the test header in the pump house, water tanks level documentation, as well as linen storage area monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Sprinkler System - Out of Service:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0354
Based on documentation review and interview, it was determined the facility failed to perform an approved fire watch throughout the building when the sprinkler system was out of service for more than 10 hours in a 24-hour period.

Findings include:

1. Review of documentation on February 8, 2019, at 1:40 PM revealed the facility did not perform fire watches throughout the building as required when the sprinkler system was out of service for more than 10 hours in a 24 hour period. The facility could only provide partial documentation after February 2, 2019, and lacked any documentation of fire watches after February 4, 2019. The sprinkler system is still not fully operational.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed that only partial fire watches were completed after February 2, 2019, and no documentation of fire watches was completed after February 4, 2019.


 Plan of Correction - To be completed: 04/09/2019

The facility is maintaining fire watches and will send documentation to the Norristown field office for review. Fire watches will continue until plans have been submitted to DOH Plan review for the sprinkler system, to include the water supply and fire pump; Plans are approved, and an occupancy inspection has been performed and approved by the Norristown Field Office.
Staff has been educated on performing fire watches.
The fire pump has been inspected and is providing protection to the facility.
Corrective Action 4/2/2019

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0355

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

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the facility was unable to provide certifications for persons performing maintenance and recharging of fire extinguishers, including kitchen suppression systems.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed fire extinguisher inspection certifications were not available at the time of survey.









 Plan of Correction - To be completed: 03/26/2019

The facility will obtain proof of certifications for persons performing maintenance and recharging of fire extinguishers, including kitchen suppression systems.

Corrective Action Date: March 26, 2019

Facility will audit proof of certifications for persons performing maintenance and recharging of fire extinguishers, including kitchen suppression systems monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

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: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively self-latch and remain smoke tight in their frames, affecting 3 of four smoke compartments.

Findings include:

1. Observation made on January 30, 2019, at 12:47 p.m., revealed there was a bedside table in front of the corridor door to room 104.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the corridor door was obstructed from closing into the frame.


2. Observation on January 30, 2019, at 12:50 pm, revealed the corridor door to resident room 109 was hitting the door frame and would not latch when closed.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the door failed to positively latch.


3. Observation made on January 30, 2019, at 12:59 p.m., revealed corridor door 205 would not close and latch into the frame; the door dragged on the floor.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the corridor door would not close.


4. Observation made on January 30, 2019, at 1:00 p.m., revealed corridor door 207 was not smoke tight along the side of the lower part of the door and frame when closed.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the corridor door was not smoke tight in the frame.

5. Observation made on January 30, 2019, at 1:20 p.m., revealed there was a hole in the tub room corridor door.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the corridor door was not smoke tight.





 Plan of Correction - To be completed: 03/26/2019

The bedside table was relocated and the facility will educate the resident that due to safety reasons the table must be stored elsewhere.

The following doors were repaired to ensure a positive latch: Room 109 and 205. Adjustments will be made to corridor door 207 to make it smoke tight. The tub room corridor door will be repaired.

Corrective Action Date: March 26, 2019

Maintenance will audit doors throughout the facility to ensure proper closing.

Maintenance will audit doors throughout facility to ensure proper closure monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide adequate square footage of smoke compartments, affecting 2 of four smoke compartments.

Findings include:

1. Observation on January 30, 2019, between 8:30 am and 2:30 pm, revealed smoke compartments 400 wing (zone two) and the first floor (zone three), Rooms 101-111 and 101-302, had zones that exceeded 22,500 square feet.

Interview at the exit conference with the Maintenance Director and Administrator on January 30, 2019, confirmed the size of the smoke compartments were larger than the maximum square footage.








 Plan of Correction - To be completed: 03/26/2019

The facility is requesting that the DOH perform an updated FSES.
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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors with a minimum 20-minute separation, affecting 2 of four smoke compartments.

Findings Include:

1. Observation made on January 30, 2019, at 12:51 p.m., revealed one leaf of the smoke barrier door's was missing a portion of the push bar hardware, outside room 111.

Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the smoke barrier door separation was incomplete.







 Plan of Correction - To be completed: 03/26/2019

The push bar hardware will be replaced outside room 111.

Corrective Action Date: March 26, 2019

Maintenance will audit smoke barrier doors are not missing push bars monthly x3 months, then as deemed necessary by the QAPI Committee. All 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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to ensure heating equipment was not exposed to combustible materials, affecting 1of four smoke compartments.

Findings Include:

1. Observation made on January 30, 2019, at 12:45 p.m., revealed there was a folded curtain on top of the heating unit inside room 102.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed combustible material housed near heating equipment.







 Plan of Correction - To be completed: 03/26/2019

The curtain was removed from on top of the heating unit inside room 102.
Staff and residents will be educated not to store items on top of heating units.

Corrective Action Date: March 26, 2019

Facility will audit resident rooms to ensure items are not being placed on top of the heating units.

Facility will audit heating units to ensure items are not stored on top of them, monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of laundry chute enclosures, affecting 1 of four smoke compartments.
Findings Include:
1. Observation made on January 30, 2019, at 1:11 p.m., revealed the linen chute room door lacked a 1-hour fire rating, per approved plan.
Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the laundry chute enclosure was incomplete.









 Plan of Correction - To be completed: 04/09/2019

Facility will obtain and install a 1 hour fire rated door for the linen chute room.

Corrective Action Date: April 9, 2019.

Maintenance will audit the laundry room chute door monthly x3 months, then as deemed necessary by the QAPI committee. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0754

Based on observation and interview, it was determined the facility failed to maintain protection of soiled linen receptacles, affecting 1 of four smoke compartments.
Findings Include:
1. Observation made on January 30, 2019, revealed there were unattended soiled linen receptacles housed in the corridor outside rooms 517 and 601.
Exit Interview with Facility Administrator and the Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the soiled linen containers were not housed in a room protected as a hazardous area.






 Plan of Correction - To be completed: 03/26/2019

The soiled linen receptacles were removed from the corridors and placed in a protected area.

Facility staff will be educated on not storing soiled linen containers in corridors.

Corrective Action Date: March 26, 2019.

Facility will conduct audits of corridors to ensure soiled linen containers are not being stored in corridors weekly x 4, then monthly x3, then as deemed necessary by the QAPI committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0761

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

Findings include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed a complete detailed annual inspection report for all fire rated doors was not available at the time of inspection.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed fire door assemblies were not inspected.










 Plan of Correction - To be completed: 03/26/2019

Facility will complete an inspection of all fire rated doors.

Maintenance staff will be educated on completing the annual inspection of fire rated doors.

Corrective Action Date: March 26, 2019.

Facility will conduct audits of fire rated door inspections quarterly or as deemed necessary by the QAPI Committee. All 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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting 1 of four smoke compartments.

Findings Include:

1. Observation made on January 30, 2019, at 12:40 p.m., revealed there was exposed electrical wiring above the south to central door separation, that was not within an electrical junction box.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the electrical wiring was not within a protective cover.








 Plan of Correction - To be completed: 03/26/2019

The electrical wiring above the south to central door separation was placed into an electrical junction box.

Facility will conduct an audit for other electrical wiring that would need to be within a protective cover.

Maintenance staff will be educated on containing connective wiring within a protective cover.

Corrective Action Date: March 26, 2019.


Facility will conduct monthly audits of wiring x 3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

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 Receptacles
Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0917

Based on document review and interview, it was determined the facility failed to maintain required testing of electrical receptacles, affecting the entire facility.

Findings include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed electrical receptacles were not tested, at resident bed locations, in areas of sedation and where anesthesia is used, for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

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

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed testing of electrical receptacles was not completed.



 Plan of Correction - To be completed: 03/26/2019

Facility will conduct testing of the electrical receptacles.

Facility will be educated on conducting testing of the electrical receptacles annually.

Corrective Action Date: March 26, 2019.

Facility will audit electrical receptacle testing quarterly x 4, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required inspections of the Essential Electrical System, affecting the entire facility.

Findings Include:

1. Documentation reviewed on January 30, 2019, between 8:30 a.m. and 2:30 p.m., revealed the following deficiencies for the emergency generator:

a. Weekly inspection/visual for January 2019;
b. Weekly visual electrolyte levels since January 30, 2018;
c. Monthly load testing for a minimum of 1/2 hour for January 2018 and January 2019;
d. Annual load bank testing report for review. Invoice dated June 18, 2018 was provided.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed inspection/testing of the emergency generator was not completed.





 Plan of Correction - To be completed: 03/26/2019

Facility will complete a weekly inspection/visual of the generator, including the electrolyte levels.
Facility will conduct a monthly load test for a minimum of 30 mins.
Facility will obtain and maintain the records of the annual load bank test.

Maintenance department will be educated on needed inspections of the generator.

Corrective Action Date: March 26, 2019.

Facility will audit generator testing documentation monthly x 3 months, quarterly x 3, then as deemed necessary by the QAPI Committee. All results will be reported to the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain proper cylinder and concentrator storage, affecting 1 of four smoke compartments.

Findings include:

1. Observation made on January 30, 2019, at 12:00 pm, revealed two walkers were leaning against oxygen storage tanks inside the physical therapy room, exposed the cylinders to abnormal mechanical shock.

Exit Interview with Facility Administrator and Director of Maintenance on January 30, 2019, at 2:30 pm, confirmed the walkers were placed against the oxygen tanks.







 Plan of Correction - To be completed: 03/26/2019

The walkers were relocated and no longer leaning on the oxygen storage tanks.

Therapy department to be educated on oxygen tanks storage.

Corrective Action Date: March 26, 2019.

Therapy will monitor storage of oxygen tanks in the department.

Maintenance will audit the storage of oxygen tanks monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.


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