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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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YORK NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on April 30, 2024, at York Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0000

Facility ID# 023802
Building 01
Center Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2024, it was determined that York Nursing and Rehabilitation Center - Center Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type V (000), unprotected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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

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

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

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

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

Observations:
Name: MAIN BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting this entire building component.

Findings include:

Document review on April 30, 2024, at 9:30 a.m., revealed the Center Bldg. has been classified as a three story, Type V (000), unprotected wood frame construction, which is fully sprinklered. The building exceeded the maximum allowable story height for an unprotected wood frame construction by two stories.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the building exceeded the maximum allowable story height for this type of construction.

Plan of Correction - To be completed: 05/31/2024

The facility requests that the DOH conducts an FSES for this deficiency.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0241

Based on document review and interview, it was determined the facility failed to provide two acceptable exits from each floor, affecting this entire building component.

Findings include:

Document review on April 30, 2024, at 9:30 a.m., revealed Center Bldg., all three floors lacked a second acceptable means of exiting from the building. Exiting from this component consisted exclusively of horizontal exits into adjacent health care buildings.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the lack of a second acceptable means of egress from each floor.

Plan of Correction - To be completed: 05/31/2024

The facility requests that the DOH conducts an FSES for this deficiency.

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 (CENTER BUILDING) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, on one of three floors.

Findings include:

Observation on April 30, 2024, at 11:40 a.m., revealed on the first floor center dining lacked a self-closing device. The room is greater than 50 square feet and contained numerous combustible boxes and various items.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the missing self-closure device.

Plan of Correction - To be completed: 05/31/2024

1. Facility immediately placed "self" closing device by first floor dining room.
2. The Maintenance Director/designee will conduct weekly audits x 4 to ensure doors are self closing.
3. Audit findings will be reported at QAPI to ensure ongoing compliance.

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 (CENTER BUILDING) - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Finding include:

Document review on April 30, 2024, at 9:30 a.m., revealed the facility could not provide documentation of the following inspections:

a. Fourth quarter, 2023 sprinkler inspection.
b. Five year internal valve and pipe inspection.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 05/31/2024

1. Fourth quarter paperwork was located and added to Life Safety book. 5-year internal valve and pipe inspection was located and added to Life Safety book.
2. Policies and documentation will be reviewed and updated Annually.
3. Administrator or Designee will audit the life safety book to ensure that all documentation was added.
4. Audit findings will be reported at QAPI to ensure ongoing compliance.

NFPA 101 STANDARD HVAC:

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 (CENTER BUILDING) - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting two of three floors.

Findings include:

Observation on April 30, 2024, revealed portable AC unit was vented directly above the ceiling in the following locations:

a. 11:10 a.m., on the second floor, Korean Director' s Office.
b. 11:25 a.m., on the first floor, office.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the venting.

Plan of Correction - To be completed: 05/31/2024

1. AC unit was removed.
2. All other offices were inspected to ensure AC units were not venting into ceiling.
3. Audit findings will be reported at QAPI to ensure ongoing compliance.

NFPA 101 STANDARD Fire Drills:

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 (CENTER BUILDING) - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly for eight of twelve required drills.

Findings include:

Document review on April 30, 2024, at 9:30 a.m., revealed the facility could not provide documentation that fire drills had been conducted for the following times:

a. First quarter- all shifts.
b. Third quarter- second and third shifts.
c. Fourth quarter- all shifts.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the missing fire drills.

Plan of Correction - To be completed: 05/31/2024

1. Moving forward facility will ensure that we conduct monthly fire drills with rotated shifts.
2. NHA or designee will educate the maintenance team on the importance of monthly fire drills.
3. NHA will audit fire drills monthly, findings will be reviewed at safety meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 (CENTER BUILDING) - Component: 01 - Tag: 0918

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

Findings Include:

Document review on April 30, 2024, at 9:30 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items, since October 13, 2023:

a. weekly visual and battery voltage.
b. monthly specific gravity testing of the battery.
c. monthly operation of transfer switches.
c. 3-year 4-hour load test.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 05/31/2024

1. Monthly testing of battery, monthly running of generator for 30 minutes and monthly operation of transfer switches has been performed and will be implemented on a monthly basis. Documentation of the 3 year, 4 hour load test have been located.
2. NHA or designee will educate the maintenance team on proper testing and the importance of relaying all findings.
3. Audits will be conducted monthly x3, findings will be reviewed at safety meeting.

Initial comments:Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0000

Facility ID# 023802
Building 02
South Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2024, it was determined that York Nursing and Rehabilitation Center - South Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (000), unprotected noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Observations:
Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting this entire building component.

Findings include:

Document review on April 30, 2024, at 9:30 a.m., revealed South Building has been classified as a three-story, Type II (000), unprotected noncombustible construction, fully sprinklered. The building exceeded the maximum allowable story height for an unprotected non-combustible construction by one story.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the facility exceeded the maximum allowable story height for this type of construction.

Plan of Correction - To be completed: 05/31/2024

The facility requests that the DOH conducts an FSES for this deficiency.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0291

Based on observation and interview it was determined the facility failed to ensure battery back-up lighting was maintained, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 11:35 a.m., revealed, on the first floor, South corridor by room 140, the battery back-up light failed to illuminate when tested.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the battery back-up light failed to illuminate when tested.

Plan of Correction - To be completed: 05/31/2024

1. Facility contacted vendor to replace battery backup light by room 140.
2. Audit conducted on all battery backup lighting to ensure they light up.
3. Audit findings will be reported at QAPI to ensure ongoing compliance.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Observations:
Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 11:35 a.m., revealed, on the second floor, Recreation- Storage Room lacked a self-closing device.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the missing self-closure device.

Plan of Correction - To be completed: 05/31/2024

1. Facility immediately placed "self" closing device by second floor, Recreation- Storage Room.
2. The Maintenance Director/designee will conduct weekly audits x 4 to ensure doors are self closing.
3. Audit findings will be reported at QAPI to ensure ongoing compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler components were maintained, affecting one of three levels.

Observation on April 30, 2024, at 11:30 a.m., revealed, on the second floor, in South Recreation Storage Room, a sprinkler was missing its escutcheon.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the missing escutcheon.

Plan of Correction - To be completed: 05/31/2024

1. Facility contacted vender to replace missing "escutcheon" in the recreation storage room.
2. Audit completed to ensure all sprinkler heads have escutcheon.
3. Audit findings will be reported at QAPI to ensure ongoing compliance.

NFPA 101 STANDARD HVAC:

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: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of three levels.

Findings include:

Document review on April 30, 2024, at 11:15 a.m., revealed, on the second floor, in South Nurse Supervisors office, a portable AC unit was vented directly above the suspended ceiling.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the venting.

NFPA 101 STANDARD Electrical Systems - Other:

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: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 10:15 a.m., revealed, on the second floor, Recreation- Storage Room duplex receptacle was missing its cover plate, exposing the inner wiring.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the exposed wiring.

Plan of Correction - To be completed: 05/31/2024

1. Plate cover was replaced
2. Audit completed to ensure all duplex receptacles have plate covers
3. Audit findings will be reported at QAPI to ensure ongoing compliance

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 12:20 p.m., revealed an unsecured oxygen cylinder, in dialysis den Nurse Station on the first floor.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the unsecured oxygen cylinder.

Plan of Correction - To be completed: 05/31/2024

1. Oxygen cylinder, in dialysis den was secured .
2. All units audited to ensure no free-standing Oxygen cylinders.
3. Dialysis team educated on the importance of not having free-standing cylinders.
4. Audit findings will be reported at QAPI to ensure ongoing compliance

Initial comments:Name: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0000

Facility ID# 023802
Building 03
North Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2024, at York Nursing and Rehabilitation Center - North Building, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (000), unprotected noncombustible building, with a ground floor, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Observations:
Name: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 11:55 a.m., revealed, on the ground floor, Laundry rated door failed to close smoke tight, due to rubbing on the floor.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the hazardous area door condition.

Plan of Correction - To be completed: 05/31/2024

1. Facility repaired ground floor laundry door and its positively latching
2. The Maintenance Director/designee will conduct weekly audits x 4 to ensure doors are self closing.
3. Audit findings will be reported at QAPI to ensure ongoing compliance

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):

Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Observations:
Name: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser (ABHR), affecting two of three levels.

Findings include:

Observations on April 30, 2024, revealed Alcohol Based Hand Rub Dispensers installed directly above duplex electrical outlets, in the following locations:

a. 10:50 a.m., on the second floor, Dining.
b. 11:00 a.m., on the first floor, Dining.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the ABHR locations.

Plan of Correction - To be completed: 05/31/2024

1. Dispensers above electrical outlets were removed and wall was repaired.
2. All dispensers audited to ensure they aren't above a outlet.
4. Audit findings will be reported at QAPI to ensure ongoing compliance

NFPA 101 STANDARD Portable Fire Extinguishers:

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: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0355

Based upon observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were accessible, affecting one of three levels.

Observation on April 30, 2024, at 10:20 a.m., revealed, on the ground floor in kitchen, the wall mounted fire extinguisher was obstructed by an ice cream freezer.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the obstructed fire extinguisher.

Plan of Correction - To be completed: 05/31/2024

1. Ice cream freezer was removed
2. NHA or designee will educate the maintenance team on the importance of ensuring all fire extinguishers are accessible.
3. NHA or designee will audit fire extinguishers monthly x3, findings will be reviewed at safety meeting.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 12:00 p.m., revealed, on the ground floor, in Breakroom, a non-GFCI outlet located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the outlet.

Plan of Correction - To be completed: 05/31/2024

1. GFCI outlet was installed.
2. NHA or designee will educate maintenance team on the importance of having GFCI outlets next to sink or any water source.
3. Audit findings will be reported at QAPI to ensure ongoing compliance

NFPA 101 STANDARD HVAC:

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: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of three levels.

Findings include:

Document review on April 30, 2024, at 11:58 a.m., revealed, on the ground floor, in Kitchen office, a portable AC unit was vented directly above the suspended ceiling.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the venting.

Plan of Correction - To be completed: 05/31/2024

1. AC unit was removed .
2. All other offices were inspected to ensure AC units were not venting into ceiling.
3. Audit findings will be reported at QAPI to ensure ongoing compliance

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0920

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

Findings include:

Observation on April 30, 2024, at 10:50 a.m., revealed, on the second floor in North Pantry, a fridge plugged into a surge protector.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 05/31/2024

1. Surge protector was removed and fridge was plugged directly wall outlet.
2. Maintenance staff will complete facility wide audit to ensure that Power Cords and Extension Cords Power strip are not being used.
3. Maintenance director or designee will complete monthly audit x3 of all pantries to ensure no Power Cords, Extension Cords, or Power strip are being used.
4. Audit findings will be reported at QAPI to ensure ongoing compliance

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Observations:
Name: BUILDING 03 (NORTH WING) - Component: 03 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of three levels.

Findings include:

Observation on April 30, 2024, at 12:20 p.m., revealed 5- unsecured oxygen cylinders, on the ground floor, in loading dock oxygen storage.

Exit Interview with the Assistant Administrator and Maintenance Director on April 30, 2024, at 12:45 p.m., confirmed the unsecured oxygen cylinders.

Plan of Correction - To be completed: 05/31/2024

1. Oxygen cylinders at loading dock were secured.
2. Facility wide audit completed to ensure no free-standing Oxygen cylinders.
3. Maintenance team and central supply educated on the importance of not having free-standing cylinders.
4. Audit findings will be reported at QAPI to ensure ongoing compliance

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