Pennsylvania Department of Health
FAIR ACRES GERIATRIC CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 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.


FAIR ACRES GERIATRIC 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 conducted on February 26 and completed on February 27, 2024, at Fair Acres Geriatric Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0000

Facility ID# 061002
Component 02
Building 05

Based on a Medicare/Medicaid Recertification Survey conducted on February 26 and completed on February 27, 2024, it was determined that Fair Acres Geriatric Center - Building 05 was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

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

Plan of Correction:

NFPA 101 STANDARD Smoking Regulations:

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.

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: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain facility smoking regulations, affecting the entire facility.

Findings include:

Observation on February 27, 2024, at 12:30 p.m., revealed, in the basement by the end of tunnel, was being used as a smoking area. This area contained numerous discarded cigarette butts strewn on the floor among debris. This is not the designated smoking area.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the smoking deficiency.

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: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two levels.

Findings include:

Observation on February 27, 2024, at 9:50 a.m., revealed, in the basement, a cut length of MC wire did not terminate properly, exposing the inner wiring.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the exposed wiring.

~Refer to 2011 edition of NFPA 70-314.28.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

Building 5 Basement MC wiring was repaired to terminate properly and no inner wiring is exposed.

Periodic checks of area for one quarter will be completed by Facilities Director or designee to ensure this condition is not replicated.

Initial comments:Name: BLDG. 6 - Component: 03 - Tag: 0000

Facility ID# 061002
Component 03
Building 06

Based on a Medicare/Medicaid Survey conducted on February 26, 2024, and completed on February 27, 2024, it was determined that Fair Acres Geriatric Center - Building 06 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 II (222) fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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

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

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

Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common walls, affecting one of four components.

Findings include:

1. Observation on February 27, 2024, at 11:15 a.m. revealed, above the fire doors separating 05/06 buildings, an unsealed penetration of the common wall, left side corner.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the penetration.

2. Observation on February 27, 2024, at 11:20 a.m. revealed the rated double doors separating 05/06 buildings failed to close smoke tight when tested.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the common wall fire door deficiency.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

1. Fire door penetration was sealed with Fire Stop Hill System NO. C-AJ-1610 flexible fire stop sealant (CP 606)

2. Door was adjusted to latch properly and be smoke tight.
Periodic checks of this area for one quarter will be completed by Facilities Director or designee to ensure this condition is not replicated.

NFPA 101 STANDARD Means of Egress - General:

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

Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting one of four levels in the facility.

Findings include:

Observation on February 27, 2024, at 10:50 a.m., revealed, on the first floor, one leaf of the smoke doors by the Dining Room failed to open.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the door failed to open.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of stairwell enclosures, affecting one of four levels in the facility.

Findings include:

Observation on February 27, 2024, at 11:17 a.m., revealed, on the ground floor, an excessive gap at the bottom of the exit door by resident room 603.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the excessive gap.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain gas cylinder and storage rooms, affecting one of four levels in the component.

Findings include:

Observation on February 27, 2024, at 10:44 a.m., revealed, on the second floor, the Supply room containing oxygen cylinders lacked signage stating: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the lack of signage.

Initial comments:Name: BLDG. 7 - Component: 04 - Tag: 0000

Facility ID# 061002
Component 04
Building 7

Based on a Medicare/Medicaid Recertification Survey conducted on February 26, 2024 and completed on February 27, 2024, it was determined that Fair Acres Geriatric Center - Building 7 was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

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

Plan of Correction:

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

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: BLDG. 7 - Component: 04 - Tag: 0355

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

Findings include:

Observation on February 26, 2024, at 12:41 p.m., revealed, on the ground floor NW, the portable fire extinguisher by resident room 109 lacked monthly inspections.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the portable fire extinguisher lacked monthly inspections.

Initial comments:Name: BLDG. 8 - Component: 05 - Tag: 0000

Facility ID# 061002
Component 05
Building 8

Based on a Medicare/Medicaid Recertification Survey conducted on February 26, 2024 and complete on February 27, 2024, it was determined that Fair Acres Geriatric Center - Building 8 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 fifteen-story, Type II (000), unprotected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

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: BLDG. 8 - Component: 05 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating of the building construction, affecting the entire building component.

Findings include:

Document review on February 26, 2024, at 8:30 a.m., revealed this building has been classified as a fifteen story, Type II (000), unprotected noncombustible construction, with a basement, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by thirteen stories.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the story height exceeded the maximum allowance for this construction type.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

Facility requests the division of life safety inspection to do a building evaluation to complete an updated FSES. Current FSES will be maintained to provide a safe enviroment for the residents. All existing fire protection systems will be monitored and kept in place.

NFPA 101 STANDARD Means of Egress - General:

Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting two of fifteen levels in the component.

Findings include:

Observation on February 26, 2024, between 10:01 a.m. and 11:28 p.m., revealed doors requiring excessive force to open in the following locations:

a. 10:01 a.m., on the ninth floor, smoke doors by resident room 909;
b. 11:28 a.m., on the ground floor, Dining Room exit door by vending machines.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the doors required excessive force to open.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

a. 8-9 Smoke Door will be repaired to assure they are smoke tight and open and close properly.

Periodic checks of door will be completed by Facilities Director or designee to ensure this condition is not replicated.

b. Ground floor dining room exit door Smoke Door will be repaired to assure they are smoke tight and open and close properly.

Periodic checks of this door will be completed by Facilities Director or designee to ensure this condition is not replicated.

NFPA 101 STANDARD Vertical Openings - Enclosure:

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0311

Based on document review and interview, it was determined the facility failed to maintain the fire resistance of vertical openings, affecting the entire building component.

Findings include:

Document review on February 26, 2024, at 8:30 a.m., revealed the facility failed to provide vertical shafts between floors with construction having a fire resistance rating of at least two hours.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the building shafts were not constructed with the proper fire resistive rating.

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: BLDG. 8 - Component: 05 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of fifteen levels in the component.

Findings include:

Observation on February 26, 2024, at 11:25 a.m., revealed, on the ground floor, the pull station by the glass exit door in the Kitchen was blocked.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the pull station was blocked.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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

Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0345

Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting one fire alarm panel.

Findings Include:

Observation on February 26, 2024, at 9:45 a.m., revealed the facility fire alarm panel was in trouble mode at time of survey.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 02/26/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

Fire alarm panel was repaired by contractor and all troubles modes were cleared.

Periodic checks of Fire Panel will be completed by Facilities Director or designee to ensure this condition is not replicated.

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: BLDG. 8 - Component: 05 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler components were maintained, affecting one of fifteen floors.

Observation on February 26, 2024, at 10:35 a.m., revealed, on the sixth floor above the ice machine, a sprinkler was missing its escutcheon.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the missing escutcheon.

Plan of Correction - To be completed: 02/27/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

Escutcheon was replaced.

Periodic checks of area will be completed for one quarter by Facilities Director or designee to ensure this condition is not replicated.

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: BLDG. 8 - Component: 05 - Tag: 0372

Based on document review and interview, it was determined the facility failed to ensure smoke barriers maintained a fire resistance rating, affecting the entire building component.

Findings include:

1. Document review on February 26, 2024, at 8:30 a.m., revealed the facility failed to provide smoke barriers constructed with at least a one-half hour fire resistance rating on all floors within the building.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed smoke barrier partitions were incomplete.

2. Observation on February 26, 2024, at 10:20 a.m., revealed, on the eighth floor above the smoke doors by room 720, an unsealed penetration around a sprinkler pipe.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the penetration.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

9 Floor Center Hall was sealed with Fire Stop Hill System NO. C-AJ-1610 flexible fire stop sealant (CP 606).

Periodic checks of this area for one quarter will be completed by Facilities Director or designee to ensure this condition is not replicated.

8 th floor above smoke doors was sealed with Fire Stop Hill System NO. C-AJ-1610 flexible fire stop sealant (CP 606).

Periodic checks of this area for one quarter. will be completed by Facilities Director or designee to ensure this condition is not replicated.

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: BLDG. 8 - Component: 05 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barrier doors, affecting one of fifteen levels in the component.

Findings include:

1. Observations on February 26, 2024, revealed smoke doors failed to close together, in the following locations:

a. 10:00 a.m., on the ninth floor by room 920.
b. 10:54 a.m., on the fifth floor, by the Service Elevator.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the doors failed to close together.

2. Observations on February 26, 2024, revealed on the eighth floor smoke doors by room 820 had open holes by the handle.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed smoke door deficiency.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

1 a. 8-9 Smoke Door will be repaired to assure they are smoke tight and open and close properly.

1 b. 8-5 Smoke Door will be repaired to assure they are smoke tight and open and close properly.

Periodic checks of these doors will be completed monthly by Facilities Director or designee to ensure this condition is not replicated.

2 8-8 Smoke Door was repaired using screws to assure they are smoke tight.

Periodic checks of this door will be completed by Facilities Director or designee to ensure this condition is not replicated.

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: BLDG. 8 - Component: 05 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of fifteen levels in the component.

Findings include:

Observation on February 26, 2024, at 9:59 a.m., revealed storage within three feet of the electrical panels in the Electric Closet on the ninth floor. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

Exit interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the improper storage in front of the electrical panels.

Plan of Correction - To be completed: 03/15/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

Storage items were immediately removed and staff was educated not to store items near or in the electrical closet.

Periodic checks of this area will be completed for one quarter by Facilities Director or designee to ensure this condition is not replicated.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for linen chutes, affecting two of fifteen levels.

Findings include:

Observations on February 26, 2024, revealed the following laundry chute deficiencies:

a. 10:10 a.m., on the eighth floor, linen chute door propped open with a laundry cart.
b. 10:25 a.m., on the seventh floor, linen chute door propped open with a laundry cart.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the chute deficiencies.

Plan of Correction - To be completed: 02/26/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

8th floor laundry cart was moved so chute could close properly and staff was educated on not to prop open linen chute.

7 th floor laundry cart was moved so chute could close properly and staff was educated on not to prop open linen chute.

Periodic checks of these areas will be completed for one quarter by Facilities Director or designee to ensure this condition is not replicated.

NFPA 101 STANDARD Electrical Systems - Other:

Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of fifteen floors.

Findings include:

Observation on February 26, 2024, at 9:30 a.m., revealed the domestic hot water electrical box was missing its protective cover, on the thirteenth floor, in the upper mechanical room.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the exposed wiring.

~Refer to 2011 edition of NFPA 70-314.28.

Plan of Correction - To be completed: 02/26/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

13 th floor domestic hot water electrical box cover was replaced.

Periodic checks of these area will be completed for one quarter by Facilities Director or designee to ensure this condition is not replicated.

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: BLDG. 8 - Component: 05 - Tag: 0920

Based on observation and interview it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of fifteen levels.

Findings include:

Observation on February 26, 2024, at 11:00 a.m., revealed, a surge protector plugged into a surge protector, on the third floor, in the day room by TV cabinet.

Exit Interview with the Director of Facilities on February 27, 2024, at 12:15 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 02/26/2024

Preparation and submission of this
POC is required by State and Federal
law. This POC does not constitute an
admission for purposes of general
liability, professional malpractice, or
any other court proceedings.Preparation
and submission of this POC is required
by State and Federal law. This POC
does not constitute an admission for
purposes of general liability, professional malpractice, or any other court proceedings.

3rd floor surge protector was removed and staff was educated on the use of surge protectors

Periodic checks of these areas will be completed for one quarter by Facilities Director or designee to ensure this condition is not replicated.

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