Pennsylvania Department of Health
HILLCREST CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 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.


HILLCREST 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 July 30, 2024, it was determined that Hillcrest Center 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)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program:

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)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Observations:
Name: - Component: -- - Tag: 0037

Based on document review and interview, it was determined that the facility failed to provide documentation of initial and annual Emergency Preparedness training for staff and individuals providing services to the facility including volunteers, affecting entire facility.

Findings include:

Document review on July 30, 2024 between 8:30 a.m. and 10:30 a.m., revealed the facility failed to to provide initial and annual Emergency Preparedness training for individuals providing services to the facility including volunteers.

Exit interview with Adminstrator and Maintenance Director on July 30, 2024 at 12:15 p.m., confirmed the facility failed to to provide initial and annual Emergency Preparedness training for individuals providing services to the facility including volunteers.

Plan of Correction - To be completed: 09/10/2024

New employees who were hired in the last 30 days will complete the Emergency Preparedness training.
Nurse Educator and the Director of Maintenance will monitor new hires' completion of the Emergency Preparedness training for the next 30 days and randomly thereafter to ensure compliance.
The Nurse Educator will report her findings to the QAPI Committee.

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

Facility ID# 034402
Component 01
Healthcare Building

Based on a Medicare/Medicaid Recertification Survey completed on July 30, 2024, it was determined that Hillcrest Center 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 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 document review and interview, it was determined the facility failed to maintain policies and procedures for carbon monoxide alarms in close proximity to fossil fuel-burning devices in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act and maintain portable, accurate floor plans, affecting the entire facility.

Findings Include:

1. Documentation reviewed on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the facility failed to provide staff in-servicing and update the emergency/disaster manual to include carbon monoxide emergency procedures.

Interview at the exit conference with Administrator and Maintenance Director on July 30, 2024 at 12:15 p.m., confirmed carbon monoxide procedures were not available at the time of inspection.

2. Document review on July 30, 2024, at 10:30 a.m., revealed the facility failed to provide portable Life Safety Code Floor Plans that included the following information:

a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier 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. Shafts walls.

Exit interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed portable floor plans were unavailable at time of survey.

Plan of Correction - To be completed: 09/10/2024

Facility updated the emergency/disaster manual to include carbon monoxide emergency procedures.
Facility hired an outside architect to update the portable Life Safety Code Floor Plans and they include the following information:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls;
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated.
e. Required exits should be clearly noted;
f. Shafts walls.
The facility hired an architect. He will update the plans within 30-60 days from the submission of this Plan of Correction (October 18th 2024)
The Maintenance Director was educated on the need to maintain accurate and up-to-date floor plans.
NHA will audit the Emergency Manual at least yearly to ensure compliance and will report his findings to the QAPI Committee.

NFPA 101 STANDARD Building Construction Type and Height:

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 - Component: 01 - Tag: 0161

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

Findings include:

Observation and document review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the building is classified as a three story, Type V (000), unprotected wood frame construction, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by two stories.

Exit Interview with the Administrator and Director of Maintenance on July 30, 2024, at 12:15 p.m., confirmed the story height exceeded the maximum allowance for this construction type.

Plan of Correction - To be completed: 09/10/2024

The center requests that Division of Life Safety conduct a FSES Survey

NFPA 101 STANDARD Egress Doors:

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.

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 exit egress doors equipped with delayed egress locking arrangements, affecting one of three levels.

Findings include:

Observation on July 30, 2024, at 10:30 a.m., on the third floor at stairtower door, revealed the exit door equipped with delayed egress locking arrangements did not release after 15 seconds of applying pressure against the crash bar.

Exit interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the doors did not release after 15 seconds of pressure against the crash bar.

Plan of Correction - To be completed: 09/10/2024

The third floor at the stair tower exit door equipped with delayed egress locking arrangements was fixed and it does release after 15 seconds of applying pressure against the crash bar.
The Maintenance Director audited all other stair tower doors equipped with delayed locking arrangements to ensure they release after 15 seconds of applying pressure against the crash bars.
The Maintenance Director will check stair tower doors equipped with delayed locking arrangements to ensure they release after 15 seconds of applying pressure against the crash bars every 6 months.
The Maintenance Director will report his findings to the NHA and the QAPI Committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0291

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

Findings include:

Document review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the facility could not provide documented reports of the following:

a. Battery back-up lighting check (monthly)
b. 90 minute test was performed within the last 12 months. (annual)

Exit interview with the Administrator and the Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 09/10/2024

Facility performed:
a. Battery back-up lighting check conducted on 7/31/24.
b. A 90 minute test was performed on 12/29/2023. Facility in possession of the documentation.
Facility will be able to provide documented reports of the following: a. Battery back-up lighting check b. 90-minute test, when requested.
Maintenance director was educated on the required tests.
Maintenance director will maintain the needed documentation and report his compliance to the QAPI Committee.

NFPA 101 STANDARD Exit Signage:

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

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on documentation review and interview, it was determined the facility failed to maintain exit and directional signs, affecting the entire facility.

Findings include:

Documentation review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the monthly exit signage inspection reports were not available at time of survey.

Exit interview with Adminstrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the unavailability of reports at time of survey.

Plan of Correction - To be completed: 09/10/2024

The monthly Exit Signage Inspection reports are now available completed on 8/16/2024
The Maintenance Director was educated on the proper location and method to save and keep his monthly Exit Signage Inspection reports.
NHA will audit monthly Exit Signage Inspection reports to ensure compliance and will report his findings to the QAPI Committee.

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 document review and interview, it was determined the facility failed to ensure kitchen equipment was inspected and serviced at required intervals, affecting three of four inspections.

Findings include:

1. Document review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the facility could not produce documentation showing the kitchen suppression system inspection was performed twice per year. Documentation provided at the time of survey was dated June 27, 2024.

Exit Interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the missing documentation.

2. Document review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the facility could not produce inspection report documentation showing kitchen exhaust hood/duct cleaning had been performed twice in the prior year.

Exit Interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 09/10/2024

The kitchen's suppression system inspection was performed on June 27th 2024 and will be completed again within 6 months.

The Maintenance Director was educated on the need to have the kitchen suppression system inspected twice per year.

NHA will audit the kitchen equipment inspections every 6 months to ensure compliance.

NHA will report his findings to the QAPI Committee.

Kitchen exhaust hood/duct cleanings were performed twice in the prior year and the facility received the reports from the vendor (Cintas).
The Maintenance Director was educated on the need to have the kitchen exhaust hood/duct inspected twice per year and he must have the actual reports from the vendor.

NHA will audit the kitchen equipment inspections every 6 months to ensure compliance.
NHA will report his findings to the QAPI Committee.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to provide/maintain initiation of the required fire alarm system, affecting one of three levels.

Findings Include:

Observation on July 30, 2024, between 11:40 a.m. and 12:05 p.m., revealed the following fire alarm deficiencies:

a. 11:40 a.m., on the first floor, the fire alarm pull station outside resident room 128 was not readily accessible due being blocked at time of survey by a sitting chair and several wheelchairs.
b. 12:05 p.m., on the first floor, inside Environmental Services office, fire alarm pull station not readily accessible due to being blocked at time of survey.

Exit interview with Adminstrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the fire alarm pull station in the listed locations were blocked by obstructions.

Plan of Correction - To be completed: 09/10/2024

The fire alarm pull station outside resident room 128 is now readily accessible. A sitting chair and several wheelchairs no longer block it.
On the first floor, inside the Environmental Services office, the fire alarm pull station is now readily accessible and is no longer blocked.

Maintenance Director / Designee audited all fire alarm pull stations around the facility to ensure they are not blocked and are readily accessible.

Maintenance Director / Designee conducted education with facility staff to ensure they are aware that all fire alarm pull stations must be readily accessible and not blocked.

Maintenance Director will conduct weekly rounds for 4 weeks and randomly thereafter to ensure compliance.

Maintenance Director will report his findings to the QAPI Committee.

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 ensure automatic sprinkler systems were inspected and maintained, affecting one of three levels in the facility.

Findings Include:

Observations on July 30, 2024, between 11:55 a.m. and 12:00 p.m., revealed the following sprinkler deficiencies:

a. 11:55 a.m., on the first floor, the resident laundry had buildup of lint/ dust on sprinkler head which could delay activation.
b. 12:00 p.m., on the first floor, the storage off employee lounge had several ceiling tiles not installed which could delay the activation of sprinklers.

Exit interview with Adminstrator and Maintenance Director on July 30, 2024, at 12:15 pm, confirmed the above stated sprinkler deficiencies.

Plan of Correction - To be completed: 09/10/2024

On the first floor, in the resident laundry room, the buildup of lint/ dust on the sprinkler head was cleaned.
On the first floor, the storage room ceiling tiles were replaced.
Maintenance director audited other storage rooms to ensure no ceiling tiles are missing.
Maintenance Director will include storage rooms in his weekly Maintenance rounds to ensure no ceiling tiles are missing.
NHA will include the storage rooms in his facility rounds.
NHA will report to the QAPI his findings for the next three months.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain inspections of portable fire extinguishers, affecting one of three levels.

Findings include:

Observation on July 30 , 2024, between 10:30 a.m. and 12:15 p.m. revealed the following:

a. 10:30 a.m., on the first floor, fire extinguisher at exit door from lounge lacked monthly inspections;
b. 12:00 p.m., on the first floor, outside room 128, portable fire extinguisher not readily accessible due to being blocked at time of survey by a sitting chair and several wheelchairs;
c. 12:05 p.m., on the first floor, inside Environmental Services office, not readily accessible due to being blocked at time of survey.
d. 12:15 p.m., on the first floor, fire extinguisher inside boiler room lacked monthly inspections.

Exit interview with Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the existence of these conditions.

Plan of Correction - To be completed: 09/10/2024

On the first floor, fire extinguisher at exit door from lounge was inspected.
On the first floor, outside room 128, the portable fire extinguisher is now readily accessible. The sitting chair and several wheelchairs were removed.
On the first floor, inside the Environmental Services office, the fire extinguisher is now readily accessible.
On the first floor, the fire extinguisher inside boiler room was inspected.
Maintenance director was educated on the requirements to keep fire extinguishers inspected monthly and readily accessible.
The Maintenance Director will inspect the fire extinguishers monthly to insure compliance.
Maintenance director will report his findings to the QAPI Committee.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch, affecting one of three levels.

Findings Include:

Observations on July 30, 2024, between 10:50 a.m. and 10:48 a.m., revealed the following:

a. 10:50 a.m., on the third floor, Spa door across from Nurses station had paper towels stuffed into the doorframe strike plate which inhibited the door ability to latch.
b. 10:48 a.m., on the third floor, Clean Utility closet had paper towels stuffed into the doorframe strike plate which inhibited the door ability to latch

Exit interview with Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the listed corridor doors inability to latch.

Plan of Correction - To be completed: 09/10/2024

On the third floor, Spa door across from Nurses station was cleared from paper towels stuffed into the doorframe.
On the third floor, the Clean Utility Room door was cleared from paper towels stuffed into the doorframe.
The Maintenance Director audited all other fire doors to ensure no other objects are stuffed into the door frames.
The Maintenance Director will educate facility staff not to stuff the doorframes of facility doors.
NHA will audit doorframes weekly for 4 weeks and randomly thereafter.
NHA will report his findings to the QAPI Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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.

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation, document review, and interview, it was determined the facility failed to ensure smoke compartments did not exceed minimum travel distances, affecting two of six smoke zones.

Findings include:

Observation on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the following smoke compartments travel distances were in excess of 200 feet, at the following locations:

a. 3:00 p.m., on the second floor, South Short Hall and Administrative Wing;
b. 11:30 a.m., on the first floor, South Short Hall and Service Wing.

Exit Interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the travel distances.

Plan of Correction - To be completed: 09/10/2024

The center requests that Division of Life Safety conduct a FSES Survey

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the smoke barrier walls, affecting two of six smoke compartments.

Findings Include:

Observation on July 30, 2024, at 11:35 a.m., revealed on the second floor, above the double doors, next to community room there are multiple unsealed penetrations of smoke barrier wall above ceiling. In between (under) structural (I) Beam and (above) partition wall. facing towards nurse station in doorway.

Exit Interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the penetrations.

Plan of Correction - To be completed: 09/10/2024

On the second floor, above the double doors, next to community room, the multiple penetrations of smoke barrier wall above ceiling were sealed with Fireblock sealant, R136, STC rating 52 made by Meatcaulk

The Maintenance Director will inspect smoke barrier walls, above the ceilings, as part of his monthly rounds and will seal as needed.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barriers, affecting two of six smoke compartments.

Findings include:

Observation on July 30, 2024, at 11:20 a.m., revealed the double doors at the nurses station, on the second floor, failed to close tight.

Exit interview with Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed smoke tight resistance was not maintained.

Plan of Correction - To be completed: 09/10/2024

The double doors at the nurses' station, on the second floor, were adjusted and now close tight.

The Maintenance Director audited other double doors to ensure they closed tight.

The Maintenance Director will audit double doors every six months to ensure they close tight.

The Maintenance Director will report his findings to the QAPI Committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, Section 110.26(A)(1) and 210.8(B)5 for electrical wiring and equipment, affecting three of three levels in the component.

Findings include:

1. Observations on July 30, 2024, between 10:30 a.m. and 12:15 p.m., revealed obstructions within three feet of the electrical panels in the following locations:

a. 10:35 a.m., on the third floor, ice room- Multiple files cabinets located in front of electrical panels;
b. 10:40 a.m., on the third floor, nurses station- Desk with equipment on it directly in front of electrical panels;
c. 11:15 a.m., on the second floor, nurses station- Desk with equipment on it directly in front of electrical panels;
d. 11:45 a.m., on the first floor, nurses station- Multiple document carts located in front of electrical panels;
e. 12:00 p.m., on the first floor, Mechanical Repair Room- Multiple storage items located in front of electrical panels and Automatic Transfer Switch (ATS) for emergency generator.

Exit interview with the Administrator and the Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the improper storage in front of the electrical panels.

2. Observation on July 30, 2024, between 10:30 a.m. 12:15 p.m., revealed non-identifiable GFCI receptacles inside multiple resident bathrooms, within six feet of sinks, on the second and third floors.

Exit interview with the Administrator and the Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed unprotected electrical recepticles.

Plan of Correction - To be completed: 09/10/2024

On the third floor, the ice room- the multiple file cabinets, located in front of electrical panels, were removed.
On the third floor, nurses' station- the desk with equipment on it, directly in front of electrical panels, was cleared of all items. The electrical panels are not obstructed.
On the second floor, nurses' station- The desk with equipment on it directly in front of electrical panels was cleared of all items. The electrical panels are not obstructed.
On the first floor, nurses station- all multiple document carts located in front of electrical
panels were removed. The electrical panels are not obstructed.
On the first floor, in the Mechanical Repair Room- Multiple storage items located in front of electrical panels and Automatic Transfer Switch (ATS) for the emergency generator were removed.
The Maintenance Director conducted in-services to educate the staff on requirements to ensure the electrical panels are not blocked by any objects.
The Maintenance Director will audit three floors and the Boiler Room, weekly for 4 weeks and randomly thereafter, to ensure the electrical panels are not obstructed or blocked.
The Maintenance Director will report his findings to the QAPI Committee.

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 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain required testing/inspection of Heating, Ventilating and Air Conditioning equipment, affecting the entire facility.

Findings include:

Document review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the report for exercising and inspection of facility fire/smoke dampers was not available or provided at time of survey. Time of survey exceeded the minimum 4-year inspection time frame requirement.

Exit interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the HVAC equipment required maintenance.

Plan of Correction - To be completed: 09/10/2024

Facility fire/smoke dampers inspection will be conducted before September 9th 2024.

Maintenance director was educated on the requirement to have this inspection every 4 years.

The Maintenance Director included this inspection in his Maintenance Department calendar in TELLS.

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 documentation review and interview, it was determined the facility failed to provide smoking regulations, affecting the entire facility.

Findings include:

Documentation reviewed on July 30, 2024, between 8:30 a.m. and 10:30 a.m. revealed the facility was unable to produce Smoking/ Non-smoking regulations for review at time of survey.

Exit interview with the Administrator and Maintenance Director on July 30, 2024 at 12:15 p.m., confirmed the unavailable Smoking Regulations at time of survey.

Plan of Correction - To be completed: 09/10/2024

Facility developed a Smoking/ Non-smoking policy and it is now part of the facility Emergency manual.

The Maintenance Director was educated on the need for a Smoking Policy even though the facility is Smoke Free.

NHA will audit the Emergency manual yearly to ensure compliance.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting the entire facility.

Findings include:

Document review on July 31, 2024, between 8:30 a.m. and 10:30 a.m., revealed written records of annual fire door inspection and testing were not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 09/10/2024

Written records of annual fire door inspection and testing are now available.
Maintenance director was educated on the annual requirement and the procedure of inspecting doors.
Maintenance director will report to the NHA the completion of the annual inspection on a yearly basis.
NHA will report the completion of the annual test to the QAPI Committee.

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

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

Findings Include:

Observations on July 30, 2024, between 10:55 a.m. and 10:53 a.m., revealed the following:

a. 10:55 a.m., on the second floor, outside of resident room 217, above ceiling, a junction box with duct tape and incorrectly sized cover was present;
b. 10:53 a.m., on the second floor, Bath /Shower, the Hoyer Lift battery charger device with wall-bracket, was no longer attached to the wall. It was plugged into a power source and resting on top of the bathtub.

Exit interview with Administrator and Maintenance Director on July 30, 2024 at 12:15 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 09/10/2024

On the second floor, outside of resident room 217, above the ceiling, the junction box with duct tape and incorrectly sized cover was replaced.
On the second floor, Bath /Shower, the Hoyer Lift battery charger device with a wall-bracket, was re-attached to the wall.
The Maintenance Director will include the Shower Rooms in his weekly rounds to ensure battery chargers are mounted correctly to the wall.
NHA will audit the Shower Rooms weekly for 4 weeks to ensure compliance.
NHA will report his findings to the QAPI Committee.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations, affecting the entire facility.

Findings include:

Document review on July 30, 2024, at between 8:30 a.m. and 10:30 a.m., revealed the facility was unable to provide documentation showing that annual receptacle testing at patient bed locations was performed during the previous 12 months. Documentation submitted at time of survey did not provide record of time or date of inspection or repairs.

Exit Interview with the Administrator and Director of Maintenance on July 30, 2024, at 12:15 p.m., confirmed the documentation was unavailable at time of survey.

Plan of Correction - To be completed: 09/10/2024

Facility annual receptacle testing at patient bed locations was performed on 8/5/2024

Maintenance Director was educated on the required annual inspection and the needed documentation.

Maintenance Director will conduct the yearly inspection and report it to the NHA

NHA will report the completion of the inspection to the QAPI Committee.

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, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

1. Document review on July 30, 2024, between 8:30 a.m. and 10:30 a.m., revealed the facility could not produce complete documentation for the following tests and inspections:

a. Monthly inspection of battery electrolyte specific gravity or conductance testing;
b. Weekly inspection of battery electrolyte levels or battery voltage;
c. 3 year, 4- Hour Load Test.

Exit interview with the Administrator and Maintenance Director on July 30, 2024, at 12:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 09/10/2024

The generator Monthly inspection of battery electrolyte specific gravity or conductance testing was completed on 7/1/2024 and 8/1/2024
Weekly inspection of battery electrolyte levels or battery voltage was completed on 8/6/, 8/12/24 and 8/19 2024
3 year, 4- Hour Load Test was completed on August 16th 2024.
Maintenance director was educated on the required inspections and tests of the generator.
Maintenance Director will utilized the TELLS system to track generator inspection schedules as well as to generate the needed reports.
NHA will audit the TELLS system monthly for 3 months to ensure inspections and tests are conducted timely.
NHA will report his findings to the QAPI Committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prevent the improper and unauthorized use of electrical devices, affecting two of three levels in the facility.

1. Observations on July 30, 2024 revealed the following:

a. 10:55 a.m, on the third floor, Medical Records Office- Refrigerator plugged into power strip;
b. 11:05 a.m, on the second floor, Nurses station- Refrigerator plugged into power strip;
c. 11:15 a.m, on the second floor, Office next to Director of Nursing- Refrigerator plugged into power strip;
d. 11:17 a.m, on the second floor, Office across from Social Services- Microwave plugged into power strip;
e. 11:20 a.m, on the second floor, Administrator office- Coffee maker plugged into extension cord multiplier.

Exit interview with Administrator and Maintenance Director on July 30, 2024 at 12:15 p.m., confirmed the unauthorized use of electrical devices at time of survey.

Plan of Correction - To be completed: 09/10/2024

On the third floor, Medical Records Office- Refrigerator is no longer plugged into power strip;
On the second floor, Nurses station- Refrigerator plugged no longer plugged into power strip;
On the second floor, Office next to Director of Nursing- Refrigerator no longer plugged into power strip;
On the second floor, Office across from Social Services- Microwave no longer plugged into power strip;
On the second floor, Administrative office- Coffee maker no longer plugged into extension cord multiplier.
Maintenance Director conducted in-Services to ensure staff is educated on the proper usage of electrical devices and surge protectors / extension cords.

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