Pennsylvania Department of Health
HARBORVIEW REHABILITATION AND CARE CENTER AT DOYLESTOWN
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HARBORVIEW REHABILITATION AND CARE CENTER AT DOYLESTOWN
Inspection Results For:

There are  49 surveys for this facility. Please select a date to view the survey results.

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HARBORVIEW REHABILITATION AND CARE CENTER AT DOYLESTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on a Revisit to an Emergency Preparedness Survey completed on October 8, 2024, it was determined that Harborview Rehabilitation and Care Center at Doylestown had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.







 Plan of Correction:


403.748(b)(5), 416.54(b)(4), 418.113(b)(3), 441.184(b)(5), 482.15(b)(5), 483.475(b)(5), 483.73(b)(5), 484.102(b)(4), 485.542(b)(5), 485.625(b)(5), 485.68(b)(3), 485.727(b)(3), 485.920(b)(4), 486.360(b)(2), 491.12(b)(3), 494.62(b)(4) STANDARD Policies/Procedures for Medical Documentation: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.
§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).


[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Name: - Component: -- - Tag: 0023

Based on document review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures, which included a system of medical documentation, which preserves patient information, protects confidentiality of patient information and secures and maintains availability of records, affecting the entire component.

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed facility failed to develop Emergency Plan policies and procedures, which included a system of medical documentation, which preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the documentation was not available.

****************************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1. Not Completed. The facility failed to develop Emergency Plan policies and procedures identifying a system of maintaining and securing medical documentation. The Emergency Plan book was not available at the time of this revisit.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the documentation was not available.








 Plan of Correction - To be completed: 12/27/2024

Facility has developed a policy for the Emergency Preparedness Manual that will include a system of medical documentation, which preserves patient information, protects confidentiality of patient information and secures and maintains availability of records.
Facility staff will be educated on this policy.

NHA/designee has conducted an audit of the emergency preparedness manual to ensure this policy is maintained in the manual.

Audit will be conducted annually x1.

All results will be reported to the QAPI Committee x 3 months.

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


Facility ID# 040502
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on October 8, 2024, it was determined that Harborview Rehabilitation and Care Center at Doylestown was not in substantial 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 III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Failure to correct the following deficiencies may negate the acceptance of certain earlier deficiencies by the approved FSES.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

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

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

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

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

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

Findings include:

1. Review of documentation and observation on October 8, 2024, between 8:30 am and 11:00 am, revealed the facility has been classified as a three story, Type III (200), unprotected ordinary construction, with a basement, which is fully sprinklered. The story height exceeds the maximum allowed for this construction type.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 11:00 am, confirmed the construction type and story height of the building.

*****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The facility has been classified as a three story, Type III (200), unprotected ordinary construction, with a basement, which is fully sprinklered. The story height exceeds the maximum allowed for this construction type.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the construction type and story height of the building.










 Plan of Correction - To be completed: 12/27/2024

The facility will contact an engineering or architectural firm to evaluate the current building construction and determine the necessary corrective action required to meet or exceed the 2012 edition of the Life Safety Code. Harborview will requested an FSES with a mandatory value based on the TLW requested.


NFPA 101 STANDARD Means of Egress - General: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.
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 ensure egress was free from all obstructions, affecting one of four levels within the component.

Findings Include:

1. Observation on October 8, 2024, at 10:29 am, revealed the Mechanical Room exit door required excessive force to open.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the door required excessive force to open.

****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item. - Not Completed. The Mechanical Room exit door required excessive force to open.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the failure to maintain egress doors.








 Plan of Correction - To be completed: 12/27/2024

Facility is in process of obtaining quotes for the repair/replacement of the Mechanical Room exit door. The facility has requested a TLW to complete the project.
Facility will conduct an audit of egress doors to ensure they are free from obstruction.
Maintenance staff will be re-educated on ensuring means of egresses are free from all obstructions.
Maintenance Director or designee will audit means of egress monthly x1, then annually x 1 and as needed.
All results will be reported to the QAPI Committee.

NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

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

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed the facility could not produce documentation, of the following:

a. monthly 30-second testing;
b. annual 90-minute testing.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The facility failed to maintain and inspect emergency lighting for the following:

a. monthly 30- second testing

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the documentation was not available.

All other deficiencies listed under this tag were corrected.










 Plan of Correction - To be completed: 12/27/2024

Facility has conducted an initial audit of facility's emergency lighting for the monthly 30-second and annual 90-minute testing to ensure proper illumination and make corrective action if needed.

Maintenance staffs will be re-educated on conducting monthly inspections of exit signs and maintaining documentation of monthly exit sign inspections.

NHA/designee will conduct audits of exit sign documentation monthly x 3 and then monthly per regulations.

All results will be reported 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 document review and interview, it was determined the facility failed to maintain and inspect exit signs, affecting the entire component.

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed the facility could not produce documentation of monthly exit sign inspections.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

2. Observation on October 8, 2024, at 9:15 am, revealed all exit signs, throughout the facility, failed to illuminate.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The facility could not produce documentation of monthly exit sign inspections.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the documentation was not available.

All other deficiencies listed under this tag were corrected.






 Plan of Correction - To be completed: 12/27/2024

Facility has conducted an initial audit of facility exit signs to ensure proper illumination and make corrective action if needed.

Maintenance staff will be re-educated on conducting monthly inspections of exit signs and maintaining documentation of monthly exit sign inspections.

NHA/designee will conduct audits of exit sign documentation weekly x 4 and then monthly per regulation.

All results will be reported to the QAPI Committee monthly x 6 months.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

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

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed the facility could not produce documentation, of the following tests and inspections:

a. quarterly sprinkler inspection;
b. annual main drain testing;
c. annual control valve exercising;
d. replacement/recalibration of sprinkler gauges within the past 5 years;
e. 5-year internal valve and pipe inspection;
f. annual fire pump testing;
g. weekly fire pump runs.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

2. Observation on October 8, 2024, at 10:29 am, revealed a missing sprinkler head wrench in the sprinkler cabinet, located in the basement level Mechanical Room.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1. - Not Completed. The facility could not produce documentation, of the following tests and inspections:

a. quarterly sprinkler inspection;
b. annual main drain testing;
c. annual control valve exercising;
d. replacement/recalibration of sprinkler gauges within the past 5 years;
e. 5-year internal valve and pipe inspection;
f. annual fire pump testing;
g. weekly fire pump runs.

Exit interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the lack of documentation.


Item 2 - Not Completed. The sprinkler heads were missing a wrench in the sprinkler cabinet, located in the basement level Mechanical Room.

Exit interview with the Administrator and Maintenance Director on December 9, 2024, at 10:30 a.m., confirmed the missing sprinkler head wrench.








 Plan of Correction - To be completed: 12/27/2024

Facility contacted the fire sprinkler vendor to obtain copies of missing documentation or to have inspections completed.
a. Quarterly sprinkler inspection was conducted on 9.5.24
b. Annual main drain testing completed on 10.14.24
c. Annual control valve exercising completed on 10.14.24
d. Replacement/recalibration of sprinkler gauges last completed on 10.14.24
e. 5-year internal valve and pipe inspection completed on 10.14.24
f. Annual fire pump testing completed on 10.14.24
g. Unable to complete weekly fire pumps due to inoperable fire pump system. Currently on hourly fire watch for all shifts.
Facility have contacted the plan review department at DOH for the approval of the replacement or modification to the sprinkler(fire pump) system installation.
Maintenance staff will be educated on how to properly complete, and document weekly fire pump runs once repaired.

Facility has replaced the missing sprinkler head wrench in the sprinkler cabinet located in the basement level mechanical room.

Maintenance staff will be re-educated on the intervals of required sprinkler system testing and maintaining documentation.

NHA/designee will conduct audits of required sprinkler testing completion and documentation.

Audits will be conducted monthly x 3. All results will be reported to the QAPI Committee.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire component.

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed the facility could not produce documentation, of the following:

a. monthly inspections;
b. annual maintenance/testing;
c. service certification of the technician performing the annual maintenance/testing.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

*****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1. Not Completed. The facility failed to maintain and inspect portable fire extinguishers for the following:

a. monthly inspections.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the documentation was not available.

All other deficiencies listed under this tag were corrected.






 Plan of Correction - To be completed: 12/27/2024

The facility will conduct a monthly inspection and maintain documentation of inspection of the portable fire extinguishers located throughout the facility.
Facility also contacted fire systems vendors for missing required documentation for the annual maintenance/testing of the portable extinguishers and the service certification of the technician performing the annual maintenance/testing.
Portable fire extinguishers were annually tested by a certified technician on 12.5.23 and again on 10.14.24
Maintenance staff will be re-educated on conducting monthly maintenance inspections of portable fire extinguishers and maintaining documentation of monthly and annual maintenance/testing.

NHA/designee will conduct an audit to ensure portable fire extinguishers are being inspected monthly and have received the annual maintenance/testing.

Audits will be conducted monthly x 3. All results will be reported to the QAPI Committee.

NFPA 101 STANDARD Corridor - 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.
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, when tested, affecting three of four levels within the component.

Findings include:

1. Observations on October 8, 2024, between 9:10 am and 10:33 am, revealed there were 7 door locations failed to positively latch, when tested, at the following locations:

a. 9:10 am, 3rd floor, Room 302, entry door
b. 9:57 am, 1st floor, Pantry door, near Custodian Closet;
c. 10:10 am, basement floor, Employee Break Room, entry door;
d. 10:16 am, basement floor, Kitchen double-doors #12;
e. 10:22 am, basement floor, Kitchen double-doors #13;
f. 10:24 am, basement floor, Central Supply Room, double-doors;
g. 10:33 am, basement floor, Mechanical (Boiler) Room entry door.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the doors failed to latch, when tested.

2. Observation on October 8, 2024, at 10:22 am, revealed Central Supply Room, basement level, the entry door was obstructed from opening, due to file cabinet and box storage obstruction.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the obstruction.

****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The facility failed to ensure corridor doors were maintained, to resist the passage of smoke and positively latch, when tested in the following locations:

a. 9:10 a.m., on the third floor, Room 302, entry door
b. 9:57 a.m., on the first floor, Pantry door, near Custodian Closet;
c. 10:10 a.m., basement floor, Employee Break Room, entry door;
d. 10:16 a.m., basement floor, Kitchen double-doors #12;
e. 10:22 a.m., basement floor, Kitchen double-doors #13;
f. 10:24 a.m., basement floor, Central Supply Room, double-doors;
g. 10:33 a.m., basement floor, Mechanical (Boiler) Room entry door.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the doors failed to latch, when tested.

All other deficiencies listed under this tag were corrected.





 Plan of Correction - To be completed: 12/27/2024

Maintenance staff has readjusted the following doors to ensure a positive latch: Rm 302 entry door, 1st floor pantry door, employee breakroom entry door, basement floor central supply room, and the basement floor mechanical room entry door.
Facility staff have removed items obstructing the basement level central supply room door.
Facility was unable to readjust the two double doors (#12 and #13) in the basement floor.
Facility will secure several quotes for repairs/replacement of these doors and will request a TLW for correction of these two sets of doors.
Maintenance staff will conduct an audit of corridor doors to ensure they are maintained and positively latched.
Maintenance staff will be re-educated to maintaining corridor doors and keeping them unobstructed.
Maintenance/designee will conduct random audits of corridor doors to ensure they are maintained, have a positive latch and are unobstructed. Audit will be conducted monthly x 3 months. All results will be reported to the QAPI Committee.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 smoke barrier doors, affecting one of four levels within the component.

Findings include:

1. Observation on October 8, 2024, at 9:52 am, revealed the double corridor, smoke doors near Resident Room 107, would not close smoke tight.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the doors did not close smoke tight.

*****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. Double corridor, smoke doors near Resident Room 107, would not close smoke tight.

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the doors did not close smoke tight.




 Plan of Correction - To be completed: 12/27/2024

Facility maintenance staff will repair/readjust the smoke doors near resident room 107 to ensure the close smoke is tight.

Maintenance staff will audit other smoke barrier doors to ensure the close smoke is tight.

Maintenance staff will be re-educated on maintaining smoke barrier doors to ensure they close smoke tight.

Maintenance will conduct an audit of smoke barrier doors monthly x 3 months.

All results will be reported to the QAPI Committee for 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
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 maintain protection of electrical wiring, affecting three of four levels within the component.

Findings include:

1. Observations on October 8, 2024, between 9:22 am and 10:13 am, revealed 4 locations failed to protect electrical wiring:

a. 9:22 am, 3rd floor, Soiled-Linen Room, light switch missing its cover plate;
b. 10:03 am, 1st floor, Clean-Linen Room, light switch failed to switch to the "off" position;
c. 10:12 am, basement floor, Dietary Storage Room, wiring from ceiling light missing junction box;
d. 10:13 am, basement floor, Dietary Storage Room, wiring from ceiling penetration missing junction box.

Exit interview with the Administrator and the Director of Maintenance on October 8, 2024, at 10:30 am, confirmed the exposed wiring.

****************************************

Based on an onsite Revisit conducted on December 09, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The following locations failed to protect electrical wiring:

c. basement floor, Dietary Storage Room, wiring from ceiling light missing junction box;
d. basement floor, Dietary Storage Room, wiring from ceiling penetration missing junction box.

Exit Interview with the Administrator and the Director of Maintenance on December 9, 2024, at 3:20 p.m., confirmed the exposed wiring.

All other deficiencies listed under this tag were corrected.













 Plan of Correction - To be completed: 12/27/2024

Maintenance and vendors will make the following repairs:
a. Replace missing ceiling light junction box in the basement floor dietary storage room
replace missing junction box in the basement floor dietary storage room ceiling penetration
Maintenance staff will conduct an audit of electrical wiring protection throughout the facility.
Maintenance staff will be re-educated on maintaining protection of electrical wiring.
Maintenance/designee will conduct an audit of the facility to ensure electrical wiring is properly maintained.
Audit will be conducted annually and as needed.
All results will be reported to the QAPI Committee x 3 months.

NFPA 101 STANDARD HVAC: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.
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 HVAC systems, affecting the entire component.

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed the facility could not provide documentation, verifying fire/smoke dampers were exercised, within the past 4 years.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

***************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The facility could not provide documentation, verifying fire/smoke dampers were exercised, within the past 4 years

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 12/27/2024

Facility has contacted fire systems company to get on their schedule to have the required 4-year fire/smoke damper exercise completed. Harborview will be requesting at TLW.

Maintenance staff will be re-educated on the timeline of this required inspection and on maintaining documentation of the inspection.

NHA/designee will conduct and audit the completion of the 4-year fire damper exercise and maintain documentation of the inspection report.

Audit will be conducted monthly x3.
All results will be reported to the QAPI Committee x 3 months.


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

Findings include:

1. Review of documentation on October 8, 2024, at 8:30 am, revealed the facility could not produce documentation, of the following:

a. weekly visual inspections;
b. weekly testing of battery electrolyte levels or battery voltage;
c. 3-year, 4-hour load test.

Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the lack of documentation.

****************************************

Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:

Item 1 - Not Completed. The facility could not produce documentation of the following:

a. weekly visual inspections

Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the lack of documentation.

All other deficiencies listed under this tag were corrected.






 Plan of Correction - To be completed: 12/27/2024

Maintenance staff will be re-educated on completing weekly visual inspections of the generator and the weekly testing of the battery electrolyte levels or battery voltage. Maintenance staff developed and will start completing the required weekly inspections and testing of the generator.
Facility contacted the PM generator vendor and received documentation of the last 3-year, 4-hour bank test that was completed on 11.30.23
Maintenance staff re-educated on maintaining documentation of required testing.
NHA/designee will conduct an audit of the documentation to ensure inspections/testing are being completed as required.
Audit will be conducted monthly x 3 months.
All results will be reported to the QAPI Committee.



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