Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on November 21, 2023, at Allied Health Care Services, Inc.-William Warren, SCR., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING Component - 01
Based on a Medicaid Recertification Survey completed on November 21, 2023, Allied Health Services Inc.- William Warren, SCR., was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
HVAC
Name - MAIN BUILDING Component - 01
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:
Based on observation and interview, it was determined the facility failed to maintain air conditioning systems in one of two smoke compartments.
Findings include:
1. Observation on November 21, 2023, revealed a portable air conditioning unit located in Dorms nursing office was vented directly into the ceiling interstitial space .
Interview at the time of the exit conference with facility representatives and facility maintenance on November 21, 2023, at 10:30 am, confirmed the air conditioner was using the interstitial space as a plenum.
Plan of Correction:The portable air conditioning unit in the Dorms nursing office will be taken out of service and removed; the ceiling where the hose penetrated will be patched.
Facilities staff will be retrained on proper venting procedures to the building exterior for future set up of the portable air conditioning unit.
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