Nursing Investigation Results -

Pennsylvania Department of Health
LOYALHANNA CARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LOYALHANNA CARE CENTER
Inspection Results For:

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LOYALHANNA CARE 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 September 24, 2019 it was determined that loyalhanna Care 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(a) REQUIREMENT Develop EP Plan, Review and Update Annually:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
[The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.]

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

The emergency preparedness program must include, but not be limited to, the following elements:]
(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0004

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to review and update their emergency plan at least annually.

Findings include:

1. Interview and documentation review on September 24, 2019, at 9:00 a.m., revealed the Emergency Preparedness Plan was not updated in over 12 months.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 9:00 a.m., confirmed the EP plan was not reviewed and updated at least annually.




 Plan of Correction - To be completed: 11/05/2019

The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the annual re-licensure survey ended September 19, 2019.

1. Actions taken for the situation identified:
The Emergency Preparedness Plan was reviewed, updated and signed off as policy on 10/10/19.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the Emergency Preparedness Plan is reviewed and updated at least annually.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Emergency Preparedness, including the annual review and update, with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that the Emergency Preparedness Plan is reviewed and update annually. A tracking system will be developed to log annual reviews, audits, and inspections, including the Emergency Preparedness Plan, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

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



Facility ID# 016702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 24, 2019 it was determined that Loyalhanna Care 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 (111), protected wood frame building, without a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to perform the required monthly exit sign inspection for 12 of 12 months, affecting the entire facility.

Findings include:

1. Documentation review on September 24, 2019, at 9:55 a.m., revealed the facility lacked documentation for the monthly exit sign inspection for the previous year.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 12:30 p.m., confirmed the facility lacked documentation for 12 months of exit sign inspection at the time of the survey.





 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The facility has developed a monthly exit sign inspection form. An inspection will be completed in October.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the exit sign inspections are conducted monthly.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related Exit Signage, including the monthly inspection, with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that the exit sign inspection is conducted monthly. A tracking system will be developed to log annual reviews, audits, and inspections, including the exit sign inspection, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19

NFPA 101 STANDARD Sprinkler System - Installation:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system installation requirements in two instances, affecting one of eight smoke compartments.

Findings include:

1. Observation on September 24, 2019, revealed the following automatic sprinkler system installation deficiencies: a) 10:45 a.m., there was no sprinkler head installed in the walk in cooler in the kitchen;
b) 10:51 a.m., the sprinkler head in the receiving area near the garage door is blocked by the door when it is opened.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 12:30 p.m., confirmed the lack of automatic sprinkler coverage.







 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The sprinkler head in the loading dock area will be moved so that is fully operational when the garage door is open. The sprinkler head in the kitchen cooler will be installed.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will conduct routine sprinkler head checks to ensure that the system is fully operational.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Sprinkler System Installation with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that routine sprinkler head inspections are conducted, as required. A tracking system will be developed to log annual reviews, audits, and inspections, including routine sprinkler head inspections, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 the automatic sprinkler system in two instances affecting one of eight smoke compartments.

Findings include:

1. Observation on September 24, 2019 revealed the following:

a) 11:29 a.m., three dirty sprinkler heads in the south attic above the medical supply room;
b) 11:35 a.m., data wires laying on top of the sprinkler pipe in the south attic above the medical supply room.

Interview with the Facility Administrator and the Maintenance Staff on September 24, 2019 at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.




 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The three (3) dirty sprinkler heads in the attic area are no longer in use and will be tagged to indicate such. The data wires have been secured and are no longer laying on top of the sprinkler pipes in the attic.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will conduct routine attic sprinkler system checks to ensure that the system is properly maintained.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Sprinkler System Maintenance and Testing with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that routine sprinkler system inspections are conducted, as required. A tracking system will be developed to log annual reviews, audits, and inspections, including routine sprinkler system checks, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355
Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishing equipment in four instances, affecting three out of eight smoke compartments.

Findings include:

1. Observation on September 24, 2019, revealed the following:

a) 9:42 a.m., there was a fire extinguisher mounted at a height greater than five feet from the floor in the corridor next to personal Laundry;
b) 10:12 a.m., there was a fire extinguisher obstructed by a canvas display in the dining room;
c) 10:39 a.m., there was a fire extinguisher mounted at a height greater than five feet from the floor in the main laundry;
d) 11:25 a.m., there was a fire extinguisher obstructed by a desk in central supply.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 12:30 p.m., confirmed the fire extinguisher deficiencies.






 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The fire extinguishers on the wall next to the personal laundry room and in the main laundry room have been moved to meet the requirement of being mounted at a height no greater than five (5) feet from the floor. The canvas sign that was obstructing the fire extinguisher in the dining room has been removed, and the desk in the central supply area has also been moved so that access to the fire extinguishers is no longer impeded. The facility has developed a tracking tool for inspecting portable fire extinguishers, which will include routine height requirement and access checks.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that fire extinguishers are properly mounted and not obstructed, per requirements.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Fire Extinguishers with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.

4. Monitoring mechanisms to assure compliance:
A tracking system will be developed to log annual reviews, audits, and inspections, including ensuring fire extinguishers are not obstructed or mounted improperly, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

NFPA 101 STANDARD Fire Drills:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed yo perform three of 12 required fire drills affecting the entire facility.

Findings include:

1. Review of documentation on September 24, 2019, at 9:15 a.m., revealed the facility lacked documentation for the following required fire drills:

a) First shift in the fourth quarter of 2018;
b) First shift in the first quarter of 2019;
c) Second shift in the first quarter of 2019.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 12:30 p.m., confirmed the facility lacked documentation for the three missing fire drills.



 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The facility has developed a monthly fire drill report. The monthly drill for September was conducted on September 26, 2019.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the monthly fire drills are conducted, as required.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Fire Drills with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that monthly fire drills are conducted, as required. A tracking system will be developed to log annual reviews, audits, and inspections, including the weekly and monthly testing, including fire drills, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

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 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on September 24, 2019, at 9:50 a.m.., revealed the facility lacked documentation for annual fire door assembly inspection, completed within the past twelve months.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 12:30 p.m., confirmed the facility lacked documentation, at the time of the survey, showing that an annual inspection had been completed within the past twelve months.






 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The facility has developed an annual fire door assembly inspection form. An inspection will be completed in October.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the fire door assembly inspections are conducted annually.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Maintenance, Inspection and Testing of Doors with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that the fire door assembly inspection is conducted annually. A tracking system will be developed to log annual reviews, audits, and inspections, including the fire door assembly inspection, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, the facility failed to perform the required annual receptacle testing inspection, affecting the entire facility.

Findings include:

1. Review of documentation on September 24, 2019, at 10:00 a.m., revealed the facility lacked documentation for the required annual receptacle testing inspection.

Interview with the Facility Administrator and Maintenance Staff on September 24, 2019, at 12:30 p.m., confirmed the facility lacked documentation, at the time of the survey, for the annual required receptacle testing.




 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The facility has developed an annual receptacle testing inspection form. An inspection will be completed in October.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the receptacle testing inspections are conducted annually.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to Electrical Systems Maintenance and Testing with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that the receptacle testing inspection is conducted annually. A tracking system will be developed to log annual reviews, audits, and inspections, including the receptacle testing inspection, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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 documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing for five of 12 months.

Findings include:

1. Document review on September 24, 2019, at 10:10 a.m., revealed the emergency generator had not been exercised under a 30 minute load for the months of April, May, June, July and August, 2019, document review also revealed the emergency generator did not have weekly maintenance from March 21, 2019 until August 17, 2019 equaling 23 weeks.

Interview with the Facility Director and Maintenance Staff, on September 24, 2019, at 12:30 p.m., confirmed the required weekly and monthly generator maintenance and testing was not being performed.





 Plan of Correction - To be completed: 11/05/2019

1. Actions taken for the situation identified:
The facility has developed a weekly and monthly generator form. Weekly/monthly testing began in September.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected and will ensure that the weekly and monthly generator tests are conducted, as required.

3. System changes and measures to be taken:
The Administrator or designee will review the Life Safety requirements related to the Essential Electrical Equipment with the Director of Maintenance and the Quality Assurance Performance Improvement Committee.


4. Monitoring mechanisms to assure compliance:
The Administrator will ensure that the weekly and monthly generator testing is conducted as required. A tracking system will be developed to log annual reviews, audits, and inspections, including the weekly and monthly testing, and the Administrator will monitor compliance of this tracking system. Monitoring reports will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.


5. Date Corrective Action will be completed:
Substantial compliance is expected by 11/5/19.


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