Pennsylvania Department of Health
MONUMENTAL POST ACUTE CARE AT WOODSIDE PARK
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MONUMENTAL POST ACUTE CARE AT WOODSIDE PARK
Inspection Results For:

There are  42 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.
MONUMENTAL POST ACUTE CARE AT WOODSIDE PARK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on April 15, 2024, it was determined that Monumental Post-Acute Care at Woodside Park 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)(7), 418.113(b)(5), 441.184(b)(7), 482.15(b)(7), 483.475(b)(7), 483.73(b)(7), 485.625(b)(7), 485.920(b)(6), 494.62(b)(6) STANDARD Arrangement with Other Facilities: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(b)(7), 418.113(b)(5), 441.184(b)(7), 460.84(b)(8), 482.15(b)(7), 483.73(b)(7), 483.475(b)(7), 485.625(b)(7), 485.920(b)(6), 494.62(b)(6).

[(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:]

*[For Hospices at 418.113(b), PRFTs at 441.184,(b) Hospitals at 482.15(b), and LTC Facilities at 483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For PACE at 460.84(b), ICF/IIDs at 483.475(b), CAHs at 486.625(b), CMHCs at 485.920(b) and ESRD Facilities at 494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For RNHCIs at 403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.
Observations:
Name: - Component: -- - Tag: 0025

Based on documentation review and interview, it was determined the facility failed to provide arrangements with other facilities, affecting the entire component.

Findings include:

Documentation review on April 15, 2024, at 8:30 a.m., revealed the facility failed to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

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




 Plan of Correction - To be completed: 05/10/2024

Documentation will be provided of arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain continuity of services.
403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication: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(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 460.84(c)(3), 482.15(c)(3), 483.73(c)(3), 483.475(c)(3), 484.102(c)(3), 485.68(c)(3), 485.542(c)(3), 485.625(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at 483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Name: - Component: -- - Tag: 0032

Based on document review and interview, it was determined the facility failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means of communicating, affecting the entire facility.

Findings include:

Document review on April 15, 2024, at 8:30 a.m., revealed the facility's emergency preparedness communication plan did not include a primary and alternate means of communicating.

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




 Plan of Correction - To be completed: 04/15/2024

The facility's Emergency Preparedness Communication Plan includes the following means of communication The plan includes use of" overhead paging, land-line phones, cellular telephone (with texting), smart telephone (with internet capability)" in addition , social media will be utilized.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 041402
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2024, it was determined that Monumental Post-Acute Care At Woodside Park was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a)

This is a two-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.






 Plan of Correction:


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

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

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

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

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

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

Findings Include:

Document review on April 15, 2024, at 8:30 a.m., revealed unprotected structural steel columns and beams above the suspended ceiling assemblies, and pan-style ceiling diffusers at the ceiling level, lacked full "blanket" protection, resulting in a classification of unprotected ordinary construction. The building has been classified as two stories. The story height exceeds the maximum height allowed for unprotected ordinary construction by one story.

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




 Plan of Correction - To be completed: 04/15/2024

An analysis of the facility structure type was conducted by an engineer.
The analysis provided concluded that the "construction type of the two-story, sprinkler protected, existing health care building is permitted to be Type II (000)" Type II (000) is an unprotected non-combustible construction. The facility has been classified as a Type iii (200), unprotected ordinary construction.

A request for a Time Limited Waiver was submitted to the Director of Safety Inspection 9/8/21 to last through 1/1/2025

The FSES worksheets will be reviewed and revised by an engineer to identify if alternative corrections will be needed.

The FSES worksheets (5.5) from the 2010 edition of the NFPA Guide on Alternative Approaches to Life Safety will be included in the analysis.


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 maintain means of egress free of obstructions, affecting two of three levels in the facility.

Findings include:

Observations on April 15th, between 11:45 a.m. and 12:05 p.m., revealed doors requiring excess force to open in the following locations:

a. 11:45 a.m., on the first floor Therapy Room, exit door;
b. 12:05 p.m., in the Basement, Stairtower #3, exit door.

Exit Interview with the Maintenance Director and Assistant Administrator on April 15th, 2024, at 12:30 p.m., confirmed the doors required excessive force to open.










 Plan of Correction - To be completed: 04/15/2024

The exit door at the first floor Therapy room and the basement Stairtower #3 exit door have been repaired to allow for unobstructed means of egress.
All means of egress in the facility have been checked and are free of obstruction.
The Maintenance director or designee will conduct weekly rounds times 4 weeks to audit any areas of non-compliance and correction will be made as needed.
Results of audits will be reported in monthly QAPI.


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 faiclity failed to maintain and inspect the emergency lighting, affecting the entire facility.

Findings include:

Documentation review on April 15, 2024, at 8:30 a.m., revealed the facility could not provide documentation of monthly 30 second testing for February, March and April.

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




 Plan of Correction - To be completed: 04/15/2024

The facility will maintain and inspect the emergency lighting affecting the entire facility and provide documentation of monthly 30 second testing.
The Maintenance Director or designee will audit documentation monthly for 4 weeks.
Results of audits will be reported in monthly QAPI.


NFPA 101 STANDARD Exit Signage: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.
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 signage, affecting 3 of twelve months.

Findings include:

Documentation review on April 15, 2024, at 8:30 a.m., revealed the facility could not provide documentation of monthly exit sign inspection for February, March and April.

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





 Plan of Correction - To be completed: 04/15/2024

The facility will maintain and inspect exit signage and provide documentation of monthly inspections.

The Maintenance Director or designee will audit documentation monthly for 3 months.
Results of audits will be reported in monthly QAPI.


NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

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

Findings include:

Observation on April 15th, 2024, at 11:15 a.m., revealed on the second floor, the door to the Soiled Utility room next to room 259 failed to latch.

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




















 Plan of Correction - To be completed: 04/15/2024

The latch on the door to the Solied Utility room next to room 259 has been repaired.
All areas of the facility have been inspected to maintain the fire resistance rating of hazardous areas.
The Maintenance director or designee will conduct weekly rounds times 4 weeks to audit any areas of non-compliance and correction will be made as needed.
Results of audits will be reported in monthly QAPI.




NFPA 101 STANDARD Cooking Facilities: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.
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 observation and interview, it was determined the facility failed to maintain kitchen hood suppression system, affecting one of three levels in the facility.

Findings include:

Observation on April 15, 2024, at 11:37 a.m., revelaed the kitchen hood suppression system was missing monthly visual inspections.

Exit interview with the Administrator and Maintenance Director on April 15th, 2024, at 12:30 p.m., confirmed the lack of monthly inspections.













 Plan of Correction - To be completed: 04/15/2024

The kitchen hood suppression system was inspected.
The Maintenance Director or designee will audit documentation of inspection of the hood suppression system monthly for 3months.
Results of audits will be reported in monthly QAPI.


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting 1 of two reports.

Findings include:

Document review on April 15, 2024, at 8:30 a.m., revealed the facility could not provide documentation of a semi-annual visual inspections prior to February 20, 2024.

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




 Plan of Correction - To be completed: 06/10/2024

The semi-annual visual inspection of the fire alarm system has been conducted to ensure compliance.

Documentation of the semi-annual inspection will be maintained by the Maintenance Director.
Audits will be conducted 2x per year.



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 facility.

Findings include:

Document review on April 15, 2024, at 8:30 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Annual main drain test;
b. Annual control valve test.

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



 Plan of Correction - To be completed: 04/15/2024

The facility maintains and inspects the sprinkler system, affecting the entire facility. The annual main drain test and annual control valve test was completed on 2/19/2024.
Documentation of the annual inspection will be maintained by The Maintenance Director and audited annually.

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 facility.

Findings include:

1. Document review on April 15, 2024, at 8:30 a.m., revealed the facility could not provide a copy of the certification of the technician performing the annual fire extinguisher inspection.

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


2. Observation on April 15, 2024, at 11:37 a.m., revealed blocked portable fire extinguishers in the following locations:

a. 11:37 a.m., Kitchen, "K" rated fire extinguisher was blocked by a service cart;
b. 12:10 p.m., Annex basement corridor next to Activities Room, a bariatric chair blocking access to fire extinguisher.

Exit interview with the Administrator and the Maintenance Director on April 15th, at 12:30 p.m., confirmed the blocked fire extinguishers at time of survey.









 Plan of Correction - To be completed: 04/15/2024

The certification of the technician performing the annual fire extinguisher inspection is available.

Cart was removed from blocking The "K" rated fire extinguisher in the kitchen.
The bariatric chair was moved that was blocking access to the fire extinguisher in the Annex basement.
All fire extinguishers have been inspected to ensure that they are not blocked.

The Maintenance Director or designee will inspect the fire extinguishers monthly for 3 months.
Results of audits will be reported in monthly QAPI.


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 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 rating of the smoke barrier walls, affecting one of three levels.

Findings include:

Observation on April 15, 2024, at 12:15 p.m., revealed on the first floor, unsealed penetrations of smoke barrier wall next to stairwell at DON office by a bundle of data cables.

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






 Plan of Correction - To be completed: 04/26/2024

The penetration of the smoke barrier wall next to the stairwell at the DON office have been sealed.
All smoke barrier walls have been inspected to maintain the rating of the smoke barrier walls.
The Maintenance Director or designee will inspect monthly for 3 months.
Results of audits will be reported in monthly QAPI.


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 three levels in the facility.

Findings include:

Observations on April 15, 2024, between 11:02 a.m. and 11:22 a.m., revealed the smoke barrier doors failed to close together in the following locations:

a. 11:02 a.m., on the second floor annex, next to room 202;
b. 11:20 a.m., on the second floor, next to room 251;
c. 11:22 a.m., on the second floor, next to room 227.

Exit interview with Administrator and Maintenance Director on April 15, 2024, at 12:30p.m., confirmed the listed smoke barrier door failed to close together.


















 Plan of Correction - To be completed: 04/16/2024

The smoke barrier doors on the second floor next to rooms 202, 251 & 227 were repaired to ensure proper closure.
All smoke barrier doors were inspected to ensure compliance.
The Maintenance Director or designee will inspect monthly for 3 months.
Results of audits will be reported in monthly QAPI.



NFPA 101 STANDARD Electrical Systems - Other: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.
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 and equipment in accordance with NFPA 70.

Findings include:

Observation April 15, 2024, at 11:40 a.m., revealed an open electrical junction box behind ice maker located within facility kitchen.

Exit interview with the Adminstrator and Maintenance Director on April 15, 2024, confirmed the exposed wiring inside junction box.













 Plan of Correction - To be completed: 04/15/2024

The open electrical junction box behind the ice maker in the kitchen has been replaced.
All electrical boxes have been inspected to ensure protection of the electrical wiring and equipment in accordance with NFPA 70.
The Maintenance Director or designee will inspect monthly for 3 months.
Results of audits will be reported in monthly QAPI.


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 faiclity failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on April 15, 2024, at 8:30 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Weekly visual inspections for February, March and April;
b. Monthly testing of battery electrolyte specific gravity or conductance;
c. Annual 90 minute load bank;
d. Preventative maintenance indicating no evidence of wet stacking.

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



 Plan of Correction - To be completed: 05/10/2024

The emergency generator has been inspected . Documentation is available for the weekly visual inspections, the monthly testing of battery electrolyte specific gravity or conductance, annual 90 minute load bank & preventative maintenance indicating no evidence of wet stacking.
Audits of the documentation will be done by the Maintenance Director monthly .
Results of audits will be reported in monthly QAPI.



NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 prohibit the use of power strips, extension cords and outlet multipliers, affecting the entire facility.

Findings include:

Observations on April 15, 2024, between 11:05 a.m. and 12:22 p.m., revealed the following deficiencies:
a. 11:05 a.m., on the second floor, Annex (Group room), refrigerator plugged into a power strip;
b. 11:10 a.m., on the second floor, (Be Well) Unit manager office, refrigerator plugged a power strip;
c. 11:47 a.m., on the first floor, Nursing supervisor office, multiple refrigerators located on different walls inside office were plugged into multiple power strips;
d. 1:48 a.m., on the first floor, Nursing supervisor office, microwave plugged into an extension cord and power strip;
e. 12:00 p.m., on the first floor, Annex Dr office located next to stairwell, microwave and refrigerator plugged into a power strip;
f. 12:22 p.m., in the Basement, Staff lounge, refrigerator plugged into a power strip.

Exit Interview with the Adminstrator and Maintenance Director on April 15, 2024, at 12:30 p.m. confirmed the above deficiencies.













 Plan of Correction - To be completed: 04/16/2024

Power strip in (group room) on the annex has been removed.
Power strip from the refrigerator on the (Be Well) unit has been removed.
Power strips on the first floor and supervisor's office has been removed.
Extension cord and power strip have been removed from the Nursing supervisor's office.
Power strip has been removed from the Dr office.
Power strip has been removed from the Staff Lounge.
All power strips, extension cords and outlet multipliers have been removed from the facility.
The Maintenance Director or designee will inspect monthly for 3 months.
Results of audits will be reported in monthly QAPI.


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