Pennsylvania Department of Health
CLEPPER MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 46 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CLEPPER MANOR - 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 May 9, 2024, it was determined that Clepper Manor was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training 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.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on May 9, 2023, at 8:30 a.m., revealed the facility was unable to provide annual emergency preparedness training and testing documentation based on the facility's policies/procedures, communication plan, and risk assessment.

Interview with the maintenance supervisor and administrator on May 9, 2024, at 8:30 a.m., confirmed the emergency preparedness plan did not include this documentation at the time of the survey.

Plan of Correction - To be completed: 06/28/2024

The facility will ensure that all staff have emergency preparedness training and testing by June 28th 2024.
The administrator or his designee will ensure yearly emergency training and testing occur by adding it to the TELS system for yearly reminders.
This will be monitored in QAPI at least once a quarter by the administrator or his designee.

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

Facility ID #032902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 9, 2024, it was determined that Clepper Manor 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 two-story, Type III (211), protected, ordinary building, with a basement and unoccupied attic, that 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, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on May 9, 2024, at 8:45 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance director on May 9, 2024, at 8:45 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.

Plan of Correction - To be completed: 06/28/2024

The facility will ensure that portable and accurate floor plans are available by 6/28/2024.
The administrator or his designee will ensure the Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

The administrator or his designee will add these documents to the emergency prepareness notebooks in the facility.
This will be monitored at least quarterly by the Administrator or his designee during QAPI.

NFPA 101 STANDARD Building Rehabilitation:

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.

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0111

Based on observation and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.

Findings include:

Observation on May 9, 2024, at 9:00 a.m., revealed the outside generator had been installed in November 2023 without a plan submission to State Plan Review or a granted occupancy from the Division of Safety Inspection.

Interview with the maintenance director on May 9, 2024, at 9:00 a.m., confirmed the facility was unable to provide documentation for submitted plans at the time of the survey.

Plan of Correction - To be completed: 06/28/2024

The administrator or his designee will ensure that proper plans are submitted to the state and an inspection will be requested by 6/28/2024.

The administrator of his designee will monitor for ongoing compliance at least quarterly and discuss during QAPI if needed.

NFPA 101 STANDARD Exit Signage:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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, the facility failed to maintain exit signs on one of two building levels.

Findings include:

Observation on May 9, 2024, between 9:12 a.m. and 9:22 a.m., revealed the following exit sign deficiencies:
A. (9:12 a.m.) Main floor living room had a missing exit sign above the smoke barrier door to the Jackson Square corridor;
B. (9:22 a.m.) Main floor corridor above the smoke barrier door, located between rooms 117 and 118, had exit signs missing on both sides of the door.

Interview with the maintenance director on May 9, 2024, at 9:22 a.m., confirmed the exit sign deficiencies.

Plan of Correction - To be completed: 06/28/2024

The administrator or his designee will ensure that exit signs will be placed on the main floor living room above the smoke barrier door to the jackson Square corridor and the main floor corridor above the smoke barrier door located between rooms 117 and 118 by 6/28/2024.

The Administrator or his designee will round at least quarterly to ensure the exit signs are still mounted and in plain sight.

The administrator or his designee will report any finding during QAPI at least quarterly.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on interview with two of two kitchen staff members, the facility failed to maintain cooking facility requirements.

Findings include:

Interview on May 9, 2024, at 10:18 a.m., revealed two staff members interviewed were unaware of the location of the pull station for the ansul system.

Interview with the maintenance director on May 9, 2024, at 10:18 a.m., confirmed the facility staff were unaware of the pull station location.

Plan of Correction - To be completed: 06/28/2024

The administrator or his designee will ensure that all kitchen staff are educated on where and how to utilize the Ansul pull station by 6/28/2024.

The administrator or his designee will quiz at least two kitchen staff members two times a week for three weeks to ensure staff are aware of the ansul pull system.

The administrator of his designee will monitor for ongoing compliance and discuss in QAPI meeting at least quarterly.

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

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, the facility failed to maintain alcohol-based hand rub dispensers on one of two building levels.

Findings include:

Observation on May 9, 2024, at 9:01 a.m., revealed the basement level laundry storage/manager's room had alcohol-based hand sanitizer stored in a quantity that exceeded ten gallons.

Interview with the director of maintenance on May 9, 2024, at 9:01 a.m., confirmed the alcohol-based hand sanitizer deficiency.

Plan of Correction - To be completed: 06/28/2024

The Housekeeping manager was educated on 5/28/2024 to ensure that no more than ten gallons of hand sanitizer is stored in one place in the facility.

The administrator or his designee will round the facility at least two times a week for three weeks to ensure proper storage of alcohol-based hand sanitizer.

The administrator or his designee will discuss any findings at QAPI at least quarterly.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to maintain one of over fifty smoke detectors, affecting one of one fire alarm system.

Findings include:

Document review on May 9, 2024, at 9:10 a.m., revealed two fire alarm inspections (dated May 6, 2023 and March 5, 2024) noted a smoke detector that needed replaced in the elevator and listed its own address on FACP. The facility failed to provide any corrective documentation for the deficiency. This is a repeat deficiency from the 2023 survey.

Interview with the maintenance supervisor and administrator on May 9, 2024, at 9:10 a.m., confirmed the deficiency existed at the time of the survey.

Plan of Correction - To be completed: 06/28/2024

The administrator or his designee will ensure that the smoke detector noted in the two fire alarm inspections will meet state and federal regulations by 6/28/2024.

The administrator or his designee will monitor for any issues or changes in the fire protection of the facility and report at least quarterly at QAPI.

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, the facility failed to maintain the sprinkler system in two of seven corridors.

Findings include:

Observation on May 9, 2024, between 9:27 a.m., and 9:29 a.m., revealed the following locations had loose escutcheon plates that created a gap in the ceiling:
A. (92:7 a.m.) Main floor north hall corridor, between room 115 and room 117, had three escutcheon plates with gaps;
B. (9:29 a.m.) Main floor south wing corridor, between room 118 and room 123, had five escutcheon plates with gaps.

Interview with the maintenance director on May 9, 2024, at 9:29 a.m., confirmed the sprinkler deficiencies.

Plan of Correction - To be completed: 06/28/2024

The maintenance director tighten the three plates on the ceiling on the main floor north hall corridor between room 115 and 117 on 6/7/2024.
The maintenance director also tighten the five plates on the main floor south wing corridor, between room 118 and 123 on 6/7/2024
The administrator or his designee will round at least weekly to monitor for any adjustments that are needed.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, the facility failed to maintain smoking requirements for one of one staff smoking area.

Findings include:

Observation on May 9, 2024, at 10:22 a.m., revealed the staff smoking area, located near the kitchen, had cigarette butts on the ground among leaves and other combustibles. Cigarette butts must be placed in a safe, non-combustible container. Metal containers with a self-closing cover can be used to as non-combustible ashtrays.

Interview with the maintenance director on May 9, 2024, at 10:22 a.m., confirmed the cigarette butts were mixed with combustibles.

Plan of Correction - To be completed: 06/28/2024

The designated smoking area located near the kitchen was cleaned up and all cigerette butts were put in a non combustible container on 5/7/2024.

The administrator or his designee will monitor the smoking area at least two times a week for three weeks to ensure proper disposal of smoking products.

The administrator or his designee will discuss any finding in QAPI at least quarterly.

NFPA 101 STANDARD Electrical Systems - Other:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in two of over thirty rooms.

Findings include:

Observation on May 9, 2024, between 8:52 a.m. and 9:39 a.m., revealed the following electrical deficiencies:
A. (8:52 a.m.) Basement laundry room, in ceiling near door, had an unfastened junction box;
B. (9:39 a.m.) Main floor vending room had a wheelchair obstructing access to the electrical panel;
C. (9:39 a.m.) Main floor vending room had an unsecured electrical panel, allowing unauthorized access.

Reference: NFPA 70-110.26(A), NFPA 99-6.3.2.2.1.3, and NFPA 70-300.11(A).
Interview with the maintenance director on May 9, 2024, at 9:39 a.m., confirmed the electrical system deficiencies.

Plan of Correction - To be completed: 06/28/2024

The maintenance director ensured that the electrical panels in the basement and near the vending machine on the first floor were secured and unobstructed on 5/7/2024

The administrator or his designee will round the facility two times a week for three weeks to ensure the electrical panels are unobstructed and fastened.

The administrator or his designee will report any issue with the electrical panels at least quarterly at QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles in two of more than thirty rooms.

Findings include:

Observation on May 9, 2024, between 9:20 a.m. and 9:47 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations:
A. (9:20 a.m.) Main floor linen room, near nurse station;
B. (9:47 a.m.) Main floor ice machine, outside dietary room.

Interview with the maintenance director on May 9, 2024, at 10:47 a.m., confirmed the electrical outlet deficiencies.

Plan of Correction - To be completed: 06/28/2024

The maintenance director installed GFCI outlets on the main floor linen room, near nurses station and main floor ice machine outside dietary room on 5/9/2024.

The Administrator or his designee will report any issues with GFCI outlets and will track at least quarterly in facility QAPI 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 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain requirements for one of one essential electrical system.

Findings include:

Document review on May 9, 2024, at 10:10 a.m., revealed the facility was unable to provide documentation for monthly conductance testing between November 2023 and April 2024.

Interview with the maintenance director on May 9, 2024, at 10:10 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 06/28/2024

The facility will purchase proper equipment to conduct the conductance testing by 6/28/2024.

The administrator or his designee will implement a monthly tracking sheet to ensure timely testing.

The administrator or designee will report any issue regarding the testing at the facility QAPI meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #032902
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on May 9, 2024, it was determined that Clepper Manor 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 II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on May 9, 2024, at 8:45 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance director on May 9, 2024, at 8:45 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.

NFPA 101 STANDARD Building Rehabilitation:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0111

Based on observation and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.

Findings include:

Observation on May 9, 2024, at 9:00 a.m., revealed the outside generator was installed in November 2023 without submitted plans to State Plan Review or a granted occupancy from the Division of Safety Inspection.

Interview with the maintenance director on May 9, 2024, at 9:00 a.m., confirmed the facility was unable to provide documentation for the submitted plans at the time of the survey.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0345

Based on document review and interview, the facility failed to maintain one of over fifty smoke detectors, affecting one of one fire alarm system.

Findings include:

Document review on May 8, 2024, at 9:10 a.m., revealed two fire alarm inspections (dated May 6, 2023 and March 5, 2024) noted a smoke detector that needed replaced in the elevator and listed its own address on FACP. The facility failed to provide corrective documentation for the deficiency. This is a repeat deficiency from the 2023 survey.

Interview with the maintenance supervisor and administrator on May 8, 2024, at 9:10 a.m., confirmed the deficiency at the time of the survey.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain requirements for one of one essential electrical system.

Findings include:

Document review on May 9, 2024, at 10:10 a.m., revealed the facility was unable to provide documentation for monthly conductance testing between November 2023 and April 2024.

Interview with the maintenance director on May 9, 2024, at 10:10 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

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