Pennsylvania Department of Health
CHANDLER HALL HEALTH SERVICES, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

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CHANDLER HALL HEALTH SERVICES, INC. - 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 July 15, 2024, it was determined that Chandler Hall Health Services, Inc., had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

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.

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) 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 its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion 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 Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion 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 hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, 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 PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, 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 PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, 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 [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, 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 ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, 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 HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the 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.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI 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 response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to conduct testing exercises of the Emergency Preparedness (EP) plan, affecting the entire facility.

Findings include:

Documentation reviewed on July 15, 2024, revealed the facility failed to conduct an annual full-scale community-based or facility-based exercise of the emergency plan, in addition to a second full-scale community-based or individual, facility-based exercise or a tabletop exercise that includes a group discussion led by a facilitator.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed Emergency Preparedness training exercises were not completed.

Plan of Correction - To be completed: 08/28/2024

A community wide full scale power outage exercise was held on 8/1/2024. Maintenance staff will be in-serviced on the requirements to hold Emergency Preparedness Drills. At least 2 drills will be held per year with at least one drill being a community-based or an individual facility-based full scale exercise and the other being either a table-top or full scale exercise that is community-based or individual facility-based. The Director of Facilities or designee will ensure at least the minimum number of exercises are scheduled throughout the year and report exercises to QAPI after they are conducted.

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

Facility ID# 031402
Component 01
FNH Building

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 2024, it was determined that Chandler Hall Health Services, Inc. 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 one-story, Type V (000), unprotected wood frame building, with a partial basement and unused attic space, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to install carbon monoxide alarms in close proximity, in all locations with fossil fuel-burning devices, in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings Include:

1. Observation made on July 15, 2024, at 2:36 p.m., revealed the following carbon monoxide alarm deficiencies:

a. The Boiler room lacked installation of a CO2 alarm for the gas-fired equipment, basement;

b. The facility failed to provide staff in-servicing and update the emergency/disaster manual to include carbon monoxide emergency procedures.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed the above carbon monoxide alarm deficiencies.

2. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey, affecting the entire facility.
The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls
Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed a complete set of portable floor plans were not available at the time of survey.

Plan of Correction - To be completed: 08/28/2024

The missing CO2 detector will be installed in the Boiler room, Carbon monoxide emergency procedures will be added to the emergency/disaster manual. Staff will be in-serviced on the placement of CO2 detectors and use of the emergency manual for carbon monoxide emergency procedures. Director of Facility services or designee will audit the CO2 detectors for proper placement and report findings at the next QAPI meeting. Director of Facility services or designee will perform monthly audits for CO2 detectors and report findings at the next three monthly QAPI meetings.

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain common fire wall separation from non-healthcare buildings, affecting 1 of two levels.

Findings Include:

Observation made on July 15, 2024, between 2:50 p.m. and 3:23 p.m., revealed the following deficiencies at the main level fire separations:

a. one leaf of the double doors separating the Hick's Residence non-healthcare building had holes in the hardware;

b. the gap was approximately 1/4" inch between the double doors leading to the pool, across from activities. This exceeds the 1/8" maximum.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed fire rated separations were incomplete.

Plan of Correction - To be completed: 08/28/2024

The damaged hardware on the leaf of the door separating the Hick's Residence from the Healthcare building will be replaced. The doors leading to the pool across from activities will be adjusted to reduce the gap to allowable spacing. Maintenance staff will be in-serviced on allowable gap of fire doors. Quarterly fire door inspections will be implemented on all fire doors in the facility. The Director of Facilities or designee will report the results of Quarterly fire door inspections at the next three monthly QAPI meetings.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of obstructions, affecting 1 of two levels.

Findings Include:

Observation made on July 15, 2024, at 2:48 p.m., revealed the following egress deficiencies:

a. there was a recycling and trash bin partially obstructing the egress pathway from the basement. This exit is also used from the main level;

b. In addition, the gate at the above pathway requires special knowledge to exit through.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed the obstructions to egress.

Plan of Correction - To be completed: 08/28/2024

a. The recycling and trash bins were moved so they are no longer obstructing the fire egress pathway. The locations of the recycling and trash bins will be painted on the ground to ensure the bins stay in their proper locations. Maintenance staff will be in-serviced on the correct placement of the bins and to keep exit egresses clear. Director of Facilities or designee will monitor the location of the bins weekly and report findings at the next three QAPI meetings.

b. The special latch will be removed from the gate the gate will be held closed by spring loaded hinges. PUSH signage will be added to indicate means of egress. Maintenance staff will be in-serviced on latching requirements for gates in the path of egress. The Director of Facilities or designee will audit the gate for the next three months for compliance and report the findings at the next three QAPI meetings.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain proper release of SLA's (Special Locking Devices), in four instances, affecting 1 of two levels.

Findings Include:

Observations made on July 15, 2024, between 2:48 p.m. and 3:22 p.m., revealed delayed egress locks were not releasing exit doors properly on the main level, at the following locations:

a. the exit near the Hick's Residence, 15-second delay did not release within 15 seconds;

b. outside room 112, 15-second delay did not release;

c. outside room 212, manual override did not release the exit door;

d. outside room 309, 15-second delay did not release.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed the obstructions to egress.

Plan of Correction - To be completed: 08/28/2024

All delayed egress locks will be repaired to operate correctly and release after the 15 second delay. Maintenance staff will be in-serviced on proper operation and release times of delayed egress doors. Delayed egress doors will be inspected monthly to ensure proper operation. The Director of Facilities or designee will report the results of monthly egress door inspection at the next three monthly QAPI meetings.

NFPA 101 STANDARD Exit Signage:

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 observation and interview, it was determined the facility failed to maintain illumination of exit signs, affecting 1 of two levels.

Findings Include:

Observation made on July 15, 2024, at 1:50 p.m., revealed exit signs that were partially illuminated. or were not readily visible within the basement.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed exit signs were obscured.

Plan of Correction - To be completed: 08/28/2024

Exit signage in the basement will be repaired, replaced or moved to ensure they are fully illuminated are readily visible. Maintenance staff will be in-serviced on proper illumination and visibility of exit signage. Exit signs will be inspected monthly to ensure proper illumination and visibility. The Director of Facilities or designee will report the results of monthly exit sign inspection at the next three monthly QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 installation of sprinkler system components, affecting 1 of two levels.

Findings Include:

Observation made on July 15, 2024, at 1:50 p.m., revealed the exterior Fire Department Connection lacked signage.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed identifying signage marking the FDC connection was not provided.

Plan of Correction - To be completed: 08/28/2024

Signage indicating the FDC will be placed at the FDC. Maintenance staff will be in-serviced on proper signage at the FDC. The FDC will be inspected quarterly to ensure proper signage is posted. The Director of Facilities or designee will report the results of the inspections at the next three QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

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

Findings Include:

1. Documentation reviewed on July 15, 2024, revealed documentation for both emergency generators was unavailable at the time of survey:

a. monthly load testing;
b. monthly specific gravity or conductance testing;
c. weekly electrolyte or voltage testing;
d. the Koller generator was not tested in August, September, and December of 2023.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed the above generator testing was not completed.

2. Observation made on July 22, 2024, at 2:28 p.m., revealed battery back-up lighting was not provided at generator set locations (transformer rooms), basement.

Exit Interview with the Facility Administrator, Community Support Supervisor, Director of Facilities, and Maintenance Supervisor on July 15, 2024 at 4:00 p.m., confirmed back-up lighting was not provided.

Plan of Correction - To be completed: 08/28/2024

1. The generator paperwork will be edited to include the missing information. Maintenance staff will be in-serviced on proper documentation and testing requirements for the generators. The Director of Facilities or designee will audit the generator paperwork and testing requirements monthly to ensure compliance. Director of Facilities or designee will report the monthly audit findings at the next three QAPI meetings.

2. The missing required emergency lighting will be installed and added to the monthly emergency backup lighting inspection form. Maintenance staff will be in-serviced on requirements of emergency backup lighting at gensets and transfer switches. Director of Facilities or designee will audit the emergency backup lighting for compliance for the next three months and report the findings at the next three QAPI meetings

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