Nursing Investigation Results -

Pennsylvania Department of Health
 FAIR ACRES GERIATRIC CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FAIR ACRES GERIATRIC CENTER
Inspection Results For:
There are  43 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 completed on April 11-12, 2022 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. 1 - Component: 01 - Tag: 0000


Facility ID# 061002
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on April 11-12, 2022, it was determined that Fair Acres Geriatric Center - Building 01 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 construction, with a basement, which is fully sprinklered.






 Plan of Correction:


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: BLDG. 1 - 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, on three of over twenty doors.

Findings include:

1. Observation on April 11, 2022 at 9:07 a.m., revealed Room 109, Room 110, and the supply closet do not a have latching mechanism.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the corridor doors would not positively latch in their frames.










 Plan of Correction - To be completed: 06/06/2022

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. Building 1, Room 109, 110 and Supply Closet Doors did not have latching mechanism. New door handles were installed on all 3 doors.

identified doors will be monitored monthly for one quarter by a maintenance department designee to ensure this condition is not replicated.
6/6/2022

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: BLDG. 1 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain fire doors, affecting the entire component.

Findings include:

1. Document review on April 11, 2022, at 8:30 am, revealed the facility could not produce documentation fire doors had been inspected within the past 12 months.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the lack of documentation.




 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
K 0761
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. Due to the documentation not being available at time of Inspection on 4/11/2022 for Fire Door Inspections.

Documentation was received as of 6/6/202. These doors will be inspected monthly by Maintenance Department designee for one quarter.
6/6/2022


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 completed on April 11-12, 2022, 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 construction, with a basement, which is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to provide a fire rated stairwell, in one of two stairwells

Findings include:

1. Observation on April 11, 2022 at 11:21 a.m., revealed the North East Stairwell had a hole in the rated door.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the lack of documentation.










 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
K 0225
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. The hole revealed in the door frame of the 5NE Stairwell on the Crozer side of the building will be closed to maintain integrity of the door frame assembly and will resist the passage of smoke.

This door will be inspected/audited monthly for one quarter by a maintenance department designee to ensure the door gap remains closed.
6/6/2022


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure sprinklers were free of debris, on one of thirty sprinkler fixtures.

Findings include:

1. Observation on April 11, 2022 at 11:28 a.m., revealed the sprinkler head in the nurse station on 5 North West, had a build up of dust and dirt on the sprinkler head.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the sprinkler obstruction.






 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
K 0353
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. The debris that was revealed on the sprinklers at Nurses' Station, Unit 5NW which could delay the activation of the sprinklers will be removed so that there will be no delay of the sprinkler activation in the event of a fire.

A Maintenance Department designee will conduct an audit of these sprinklers to ensure that this condition does not replicate each month for a quarter.
6/6/2022



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: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to provide a smoke tight smoke barrier doors, in one of two smoke zones.

Findings include:

1. Observation on April 11, 2022, at 10:55 am, revealed the smoke doors on the 5 North East vacant area had holes from the removal of special locking arrangement hardware.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the smoke doors were not smoke tight.



 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
K 0374
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. The hole revealed in the door frame of the 5NE, Main Entrance to Unit on the Crozer side of the building will be closed using the proper material to maintain integrity of the door and door frame assembly and will resist the passage of smoke.

This door will be inspected/audited monthly for one quarter by a maintenance department designee to ensure the door gap remains closed.
6/6/2022



NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain fire doors, affecting the entire component.

Findings include:

1. Document review on April 11, 2022, at 8:30 am, revealed the facility could not produce documentation fire doors had been inspected within the past 12 months.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the lack of documentation.



 Plan of Correction - To be completed: 06/06/2022

K 0761
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. Due to documentation not being available at time of Inspection on 4/11/2022 for Fire Door Inspections Documentation. Documentation was received as of 6/6/2022. These doors will be inspected monthly by Maintenance Department designee for one quarter.
6/6/2022

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


Facility ID# 061002
Component 03
Building 06

Based on a Medicare/Medicaid Survey conducted on April 11-12, 2022, 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 construction, with a basement, which is fully sprinklered.










 Plan of Correction:


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: BLDG. 6 - Component: 03 - Tag: 0293

Based on observation and interview, it was determined the facility failed to provide a clear directional exit sign, on one of three floors.

Findings include:

1. Observation on April 11, 2022, at 12:47 p.m., revealed the exit sign near nurse station 2 near the group activity, lacked a faceplate to clearly show the direction of exit travel.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the direction of egress was not clearly marked.









 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
K 0293
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. Exit sign was replaced near Nurses' Station and Group Activity.

A monthly inspection by a Maintenance Department designee for one quarter will be performed to ensure sign is displayed adequately.




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: BLDG. 6 - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors securely latch in their frames, on one of three floors.

Findings include:

1. Observation on April 11, 2022, at 1:10 p.m., revealed the corridor door to room 112 does not latch in its frame.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the corridor door required adjustment.




 Plan of Correction - To be completed: 06/06/2022

K 0363
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.

b. Building 6, 1st floor, Room 112 door was adjusted to latch in its frame. This door will be monitored monthly for one quarter by a maintenance department designee to ensure this condition is not replicated.
6/6/2022

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: BLDG. 6 - Component: 03 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure smoke barriers maintained smoke tight resistance, on two of three floors.

Findings include:

1. Observation on April 12, 2022, between 12:23 and 2:00 p.m., revealed the following deficiencies:

a. at 12:23 p.m., the Fire Door near room 209 was not smoke tight in its frame. The door was equipped with a self closing device;

b. at 12:33 p.m., the Fire Door between nusring storage and the nourishment office on the 2nd floor did not latch in its frame. The door was equipped with a self closing device;

c. at 1:15 p.m., the Ground floor fire/smoke door astragel was not attached to the door securely;

d. at 1:17 p.m., the Ground floor fire/smoke doors near G09 was not smoke tight in its frame. The door was equipped with a self closing device.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed smoke barrier doors were not smoke tight.





 Plan of Correction - To be completed: 06/06/2022

K 0374
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. The smoke barrier double doors on Unit 6-2 near room 209 failed to fully close when tested will be repaired/adjusted so that the door fully closes and positively latches within its frame.

These doors will be inspected monthly by Maintenance Department designee for one quarter.
6/6/22

b. The smoke barrier double doors on Unit 6-2 between Nursing Storage and Nourishment Office failed to fully close when tested will be repaired/adjusted so that the door fully closes and positively latches within its frame.

These doors will be inspected monthly by Maintenance Department designee for one quarter.
6/6/22

c. The smoke barrier double doors on 6 Ground, fire/smoke door astragal was repaired so that the door fully closes and positively latches within its frame. These doors will be inspected monthly by Maintenance Department designee for one quarter.
6/6/22


NFPA 101 STANDARD Smoking Regulations: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.
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. 6 - Component: 03 - Tag: 0741

Based on observation and interview, it was determined the facility failed to ensure the facility maintained a smoke-free environment, based on its non-smoking policy, in one of 5 buildings.

Findings include:

1. Observation on April 11, 2022, at 2:00 p.m., revealed the basement level outside of the Hot room doors had numerous cigarette butts scattered in the area.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed evidence of smoking on the premises.






 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
K 0741
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) Where it was revealed in the basement of Building 6 outside hot room that had numerous cigarette butts on the grounds. New "No Smoking" signs installed in area and debris was cleaned up.

A Facilities Management designee will perform a weekly preventative maintenance check to ensure that this area remains clean
6/6/22


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


Facility ID# 061002
Component 04
Building 7

Based on a Medicare/Medicaid Survey conducted on April 11-12, 2022, is 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 construction, with a basement, which is fully sprinklered.








 Plan of Correction:


NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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: BLDG. 7 - Component: 04 - 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, on one of over twenty doors.

Findings include:

1. Observation on April 11, 2022, at 10:34 a.m., revealed the room across from room 101 did not have latching mechanism.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the corridor door required adjustment.




 Plan of Correction - To be completed: 06/06/2022

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.

c. Building 7, Room 101 did not have latching mechanism. New door handle was installed on door.

This door will be monitored monthly for one quarter by a maintenance department designee to ensure this condition is not replicated.
6/6/2022


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 April 11-12, 2022, 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 construction, with a basement, which 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: BLDG. 8 - Component: 05 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain the fire resistance rating of the building construction, affecting 15 of 15 floors.

Findings include:

1. Observation and document review on April 12, 2022, between 8:30 a.m. and 1:35 p.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.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the story height exceeded the maximum allowance for this construction type.








 Plan of Correction - To be completed: 06/12/2022

0161
Facility requested a time-limited waiver for K-tag K0161: The facility is currently working with an architectural firm to evaluate the current building construction and determine the necessary renovations required to meet or exceed the updated 2012 edition of the Life Safety Code. Time limited waiver until construction is complete on December 31, 2022.

Facility also requests the Division of Life Safety Inspection do a building evaluation to complete an updated FSES. Current FSES will be maintained to provide a safe environment for the residents. All existing fire protection systems will be monitored and kept in place until construction is completed by December 31, 2022



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: BLDG. 8 - Component: 05 - Tag: 0293

Based on observation and interview, it was determined the faility failed to maintain exit signs, affecting one of fifteen levels in the facility.

Findings include:

1. Observation made on April 12, 2022, at 9:16 am, revealed on the thirteenth floor, the exit sign near the freight elevator had a chevron pointing towards a wall that was not a path of egress.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the improper direction of the exit sign.





 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:
0293
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. The thirteenth floor, the exit sign near the freight elevator had a chevron pointing towards a wall that was not a path of egress. The exit sign was replaced so the egress path directs you to the required exit path. This exit sign will be inspected/audited by a maintenance department designee to ensure the chevron and sign appropriately point to the path of egress.



NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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 observation, document review and interview, it was determined the facility failed to maintain the fire resistance of vertical openings, affecting fifteen of fifteen floors.

Findings include:

1. Observation and document review on April 12, 2022, between 8:30 a.m. and 1:35 p.m., revealed the facility failed to provide vertical shafts between floors with construction having a fire resitance rating of at least two hours.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the building shafts were not constructed with the proper fire resistive rating.


2. Observation made on April12, 2022, between 8:50 am and 11:10 a.m., revealed the following deficiencies:

a. at 8:50 a.m., Stair 2 door, fire exit hardware was missing its latch plate;

b. at 11:10 a.m., in the 2nd floor nurse storage room above the cable box, there was a vertical penetration with a blue data wire running thru it.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the incomplete protection of vertical openings.











 Plan of Correction - To be completed: 06/06/2022

Plan of Correction:

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. Observation and document review revealed that the facility failed to provide vertical shafts between
floors with construction having a fire resistance rating of at least two hours.

Such deficiency is due to These voids around these vertical penetrations were due to the ongoing renovations and are being handled by the contractor.

We will perform a monthly audit for one quarter to ensure this condition does nor reoccur.


These voids around these vertical penetrations were due to the ongoing renovations and are being handled by the contractor. We will perform a monthly audit for one quarter to ensure this condition does nor reoccur.


2. Observation revealed the following deficiencies:

a. Stair 2 Door, fire exit hardware was missing its latch plate. Door was repaired with new latch plate.

b. 2nd floor Nurse Storage room above the cable box, there was a vertical penetration with blue data wire running thru it. Wire was secured and area sealed with Hilti Fire Stop.

We will perform a monthly audit for one quarter to ensure this condition does nor reoccur.



NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 maintain sprinkler system components, affecting three of fifteen levels.

Findings include:

1. Observation made on April 12, 2022, between 9:05 am and 9:52 a.m., revealed the following deficiencies:

a. at 9:05 a.m., the sprinkler head in Garbage chute room was starting to show signs of corrosion;

b. at 9:13 a.m., the sprinkler head in the linen chute room was covered in dust and lint;

c. at 9:15 a.m., on the 13th floor near the phone block, a concealed sprinkler was not mounted tight to the ceiling;

d. at 9:52 a.m., the escutcheon plate was missing from the sprinkler head in the main conference room.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the above named sprinkler deficiencies.






 Plan of Correction - To be completed: 06/07/2022

0353
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. Building 8, Ground Floor – the sprinkler head in the Garbage Chute Room was starting to show signs of corrosion. Outside Contractor was contacted to inspect/repair/replace, as necessary.

b. Building 8, Linen Chute Room – Dust and lint debris revealed on the sprinkler which could delay the activation of the sprinkler will be removed so that there will be no delay of the sprinkler activation in the event of a fire. A Maintenance Department designee will conduct an audit of these sprinklers to ensure that this condition does not replicate each month for a quarter.

c. Building 8, 13th Floor – near the phone block, a concealed sprinkler was not mounted tight enough to the ceiling. Outside Contractor was contacted to inspect/repair/replace, as necessary.

d. Building 8, Main Conference Room - The escutcheon plate was missing from the sprinkler head which could delay the activation of the sprinkler will be reattached to the sprinkler housing. The
escutcheon plate was replaced. A Facilities Management designee will perform a monthly preventative maintenance check for one quarter to ensure a duplication of this problem does not reoccur.


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: BLDG. 8 - Component: 05 - Tag: 0363

Based on observation and interview, it was determined the facility failed to corridor doors positively latched into their frames, on two of 15 floors.

Findings include:

1. Observation on April 12, 2022, between 10:38 a.m. and 11:02 a.m., revealed the following deficiencies:

a. at 10:38 a.m., the brief room door on the first floor was wedged open with the shelf holding briefs;

b. at 11:02 a.m., the nurse lounge latching mechanism was stuffed with paper towels, preventing the door from latching in its frame.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the impediments to latching the doors.








 Plan of Correction - To be completed: 06/07/2022

Plan of Correction:
0363
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. Doors revealed with impediments to closing in the following locations will be removed so that there are not any impediments for the door to close and latch within its frame in the following location:
a. Building 8, 1st Floor – the Brief Room door was wedged open with the shelf holding briefs.
b. The Nurse Lounge latching mechanism was stuffed with paper towels, preventing the door from latching in its frame.
These doors will be monitored monthly for one quarter by a maintenance department designee to ensure this condition is not replicated.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 observation and interview, it was determined the facility failed to ensure smoke barries maintained a fire resistance rating, on 15 of 15 floors

Findings include:

1. Observation on April 12, 2022, between 8:30 a.m. and 1:35 p.m., revealed the faclity failed to provide smoke barriers constructed with at least a one-half hour fire resisitance rating on all floors within the building.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed smoke barrier partitions were incomplete.






 Plan of Correction - To be completed: 06/07/2022

Plan of Correction:
0372
Facility requested a time-limited waiver for K-tag K0372: The facility is currently working with an architectural firm to evaluate the current building construction and determine the necessary renovations required to meet or exceed the updated 2012 edition of the Life Safety Code. Construction completion date is December 31, 2022

Facility also requests the Division of Life Safety Inspection do a building evaluation to complete an FSES. Current FSES will be maintained to provide a safe environment for the residents. All existing fire protection systems will be monitored and kept in place until construction is completed of December 31, 2022.

Facility also requests the Division of Life Safety Inspection do a building evaluation to complete an FSES. Current FSES will be maintained to provide a safe environment for the residents. All existing fire protection systems will be monitored and kept in place until construction is completed of December 31, 2022.


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

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

Findings include:

1. Observation made on April 12, 2022, at 11:25 am, revealed on the seventh floor, the smoke door would not close.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the smoke door would not close.





 Plan of Correction - To be completed: 06/07/2022

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. Building 8, 7th Floor - The smoke barrier double doors failed to fully close when tested will be repaired/adjusted so that the door fully closes and positively latches within its frame.

These doors will be inspected monthly by Maintenance Department designee for one quarter.


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

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

Findings include:

1. Observation made on April 12, 2022, at 10:40 am, revealed on the ninth floor, an open junction box above the ceiling between resident rooms 904 and 905.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the open junction box.



 Plan of Correction - To be completed: 06/07/2022

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. Building 8, 9th Floor - between rooms 904 and 905 where an open junction box above the ceiling by the Resident Rooms. The junction box will be repaired/replaced so that this condition does not exist.

A Facilities Management designee will perform a monthly preventative maintenance check for one quarter to ensure a duplication of this problem does not reoccur.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
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 ensure chute enclosures maintained a fire resistance rating and were secured against unauthorized access, on two of fifteen floors.

Findings include

1. Observation on April 12, 2022, between 9:18 a.m. and 10:02 a.m., revealed the following deficiencies:

a. at 9:18 a.m., outside rated door of the linen chute room was not latching in its frame. The door was equipped with a self closing device;

b. at 10:02 a.m., the chute doors on the main floor near the freight elevator room were not secured.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the chute room doors required adjustment.





 Plan of Correction - To be completed: 06/07/2022

Plan of Correction:
0541
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. Building 8 – it was determined the facility failed to ensure chute enclosures maintained a fire
resistance rating and were secured against unauthorized access, on two of fifteen floors.

a. Outside rated door of the linen chute was not latching in its frame. The door was equipped with a self-closing mechanism. The door will be repaired/adjusted/replaced by outside contractor. The door will be repaired/adjusted/replaced by outside contractor.

b. Main Floor – the chute doors near the freight elevator room were not secured. The door was secured by Facilities Management.

The Facilities Management Department will include an inspection of trash chute doors on our bi-weekly preventative maintenance rounds report so that any discrepancies related to the chute doors can be found and corrected.




NFPA 101 STANDARD Gas and Vacuum Piped Systems - Information an: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.
Gas and Vacuum Piped Systems - Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0909

Based on observation and interview, it was determined the facility failed to maintain labeling of medical gas piping, affecting one of fifteen levels in the component.

Findings include:

1. Observations made on April 12, 2022, between 10:11 am and 10:26 am, revealed missing medical gas piping labeling in the following locations:

a. 10:11 am, 10th floor, resident room 1002;
b. 10:26 am, 10th floor, resident room 1011.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the missing medical gas piping labels.



 Plan of Correction - To be completed: 06/07/2022

0909
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. Missing medical gas piping labeling in the following locations of Building 8:
a. Resident Room 8-10, 1002 – new labels placed on piping.
b. Resident Room 8-10, 1011 – new labels placed on piping.

Maintenance designee will check monthly for one quarter that labels remain on pipes.

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

Based on observation and interview, it was determined the facility failed to ensure the proper usage of power strips and extension cords, on three of fifteen floors

Findings include

1. Observation on April 12, 2022, between 10:00 a.m. and 12:40 p.m., revealed the following deficiencies:

a. at 10:00 a.m., the nurse supervisors office had a power strip that was not UL rated for coffee machines;

b. at 12:40 p.m., the thrid floor main activites area, there was an extension cord in use for a pink tree. The power strip was plugged into a power strip in the same area.

Interview at the exit conference with the Administrator and the Acting Director of Facilities on April 12, 2022, at 1:35 PM, confirmed the unauthorized use of electrical devices.




 Plan of Correction - To be completed: 06/07/2022


0920
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. The unauthorized electrical devices that were revealed in use at the time of survey will be removed and plugged into directly into a wall outlet in the following locations of Building 8:

a. Main Floor - The Nurse Supervisor Office coffee machine.

b. Third Floor – The main activities area pink tree.

A monthly inspection for one quarter by a Maintenance Department designee to ensure that this deficient practice does reoccur.



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