Pennsylvania Department of Health
BEAVER HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BEAVER HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  37 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.
BEAVER HEALTHCARE AND REHABILITATION 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 May 20, 2025, it was determined that Beaver Health Care and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.









 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004


Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to review and update their emergency plan at least annually.

Findings include:

1. Interview and documentation review on May 20, 2025, at 8:45 a.m., revealed the Emergency Preparedness Plan was not updated in over 12 months.

Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the EP plan was not reviewed and updated at least annually.












 Plan of Correction - To be completed: 06/27/2025

The facility will review and update the Emergency Preparedness Plan annually as required.
403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements: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.
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.


*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039


Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain documentation for the two required exercises to test the emergency plan.

Findings include:

1. Interview and documentation review on May 20, 2025 at 9:20 a.m., revealed the facility lacked documentation for the two exercises required annually to test the emergency plan.

Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed documentation for the two exercises were not available at the time of the survey.







 Plan of Correction - To be completed: 06/27/2025

The facility will schedule the two exercises required annually to test the emergency plan.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 070702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2025, it was determined that Beaver Health Care and Rehabilitation Center, was not in compliance with the following requirements of the Life Safety Code for an existing 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 V (000), unprotected wood frame building, without a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291


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

Findings include:

1. Documentation review on May 20, 2025, at 9:00 a.m., revealed the facility lacked documentation for an annual 90-minute test for the emergency lights.

Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the facility lacked documentation for the annual 90-minute test of the emergency lights, at the time of survey.







 Plan of Correction - To be completed: 06/27/2025

The Maintenance Director will complete the annual 90-minute emergency lighting testing by June 20th, 2025. The Maintenance Director will be educated by the Administrator or designee on K291. Annual inspection will be audited by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.
NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324


Based on observation and interview, it was determined the facility failed to maintain and inspect the kitchen hood exhaust and suppression systems in two instances, affecting the entire facility.

Findings include:

1. Observation on May 20, 2025, at 8:30 a.m., revealed the facility could not provide documentation of the following:

a) Semiannual kitchen fire suppression system testing and maintenance;
b) Semiannual kitchen exhaust hood/duct cleanings.

Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the missing cooking facility maintenance documentation.








 Plan of Correction - To be completed: 06/27/2025

A contracted vendor will complete the Semiannual fire suppression testing by June 20th, 2025. Semiannual kitchen hood cleaning will be completed by June 20th, 2025 by a contracted vendor. The Maintenance Director will be educated by the Administrator or designee on K324. Both inspections will be audited by Maintenance Director or designee for timely completion on a Semiannual basis. Findings will be reported to Quality Assurance and Performance Improvement committee meetings.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345


Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in one instance, affecting the entire facility


Findings Include:

1. Review of documentation on May 20, 2025, at 10:15 a.m., revealed the the facility lacked documentation for the semiannual visual fire alarm inspection.


Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the absence of the fire alarm system inspection documentation.







 Plan of Correction - To be completed: 06/27/2025

The Maintenance Director will complete the functionality and visual fire alarm testing completed by June 20th, 2025. The Maintenance Director will be educated by the Administrator or designee on K345. Semiannual inspection will be audited by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353


Based on document review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting the entire building.

Findings include:

1. Document review on May 20, 2025, revealed the facility lacked documentation for the following required automatic sprinkler system inspections:

a) 8:45 a.m, the five-year internal pipe and valve inspections;
b) 8:50 a.m., three of four quarterly sprinkler system inspections;
c) 8:55 a.m., the three-year Full Flow Trip Test of the dry pipe sprinkler system;


Interview with Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the missing documentation.


2. Observation on May 20, 2025, at 9:30 a.m., revealed a sidewall sprinkler head, located in the Laundry room was loaded with dryer lint.

Interview with Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the dirty sprinkler head.




 Plan of Correction - To be completed: 06/27/2025

The identified sprinkler system tests, the quarterly sprinkler system inspections, the three-year Full flow trip test of the dry pipe sprinkler system, the five-year internal pipe and valve inspections will be completed by a contracted vendor by June 20th, 2025. Identified dusty sprinkler head will be cleaned by the Maintenance Director by June 3, 2025. The Maintenance Director will be educated by the Administrator or designee on K353. A whole house sprinkler head audit for dirty sprinkler heads will be conducted by the Maintenance Director or designee. Results will be reported to the Quality Assurance and Performance Improvement committee meeting.
NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguisher inspections in two instances, affecting the entire facility. In accordance with NFPA 10, 7.1.2.1.

Findings include:

1. Review of documentation on May 20, 2025, at 8:30 a.m., revealed the following portable fire extinguisher inspection deficiencies:

a) The facility failed to provide an annual portable fire extinguisher inspection report;
b) The facility was unable to confirm if the person/persons who performed the annual portable fire extinguisher inspection are trained and certified to inspect portable fire extinguishers.

Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the listed portable fire extinguisher inspection deficiencies.











 Plan of Correction - To be completed: 06/27/2025

A contracted vendor will complete the inspections of the fire extinguishers by June 20th, 2025. The Maintenance Director will be educated by the Administrator or designee on K355. Annual inspection for fire extinguishers will be audited by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0761


Based on documentation review and interview, it was determined the facility failed to test the fire doors in one instance, affecting the entire facility.

Findings include:

1. Documentation review on May 20, 2025, at 8:35 a.m., revealed the facility failed to conduct a functional test and visual inspection of fire doors within the last 12 months.

Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 1:30 p.m., confirmed the lack of fire door inspection documentation.







 Plan of Correction - To be completed: 06/27/2025

The annual fire door assembly functionality testing will be completed by the Maintenance Director by June 20th, 2025. The Maintenance Director will be educated by the Administrator or designee on K761. Annual inspection of this audit will be conducted by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.
NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain electrical receptacles in resident rooms, affecting the entire facility.

Findings include:

1. Documentation review on May 20, 2024, at 11:30 a.m., revealed the facility failed to perform the required annual electrical receptacle inspection in resident rooms, in the last twelve months. The most recent annual inspection of electrical receptacles was performed in February of 2024.


Interview with the Facility Administrator and Maintenance Director on May 20, 2024, at 1:30 p.m., confirmed the listed electrical receptacle inspection deficiency.








 Plan of Correction - To be completed: 06/27/2025

Annual electrical outlet testing in resident rooms will be completed by the Maintenance Director by June 20th, 2025. The Maintenance Director will be educated by the Administrator or designee on K914. Annual inspection of this audit will be conducted by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918


Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in four instances, affecting the entire facility.

Findings include:

1. Review of documentation on May 20, 2025, revealed the facility lacked documentation verifying that the following items were performed in the last 12 and 36 months:

a) 9:55 a.m., the annual 90-minute load bank test;
b) 10:05 a.m., the triennial four-hour load test;
c) 10:10 a.m., the required annual Preventative Maintenance, including confirmation of no evidence of wet stacking and meeting the Manufacturer's specifications;
d) 10:15 a.m., the Annual Fuel quality test was not avilable at the time of the inspection.


Interview with the Facility Administrator and Maintenance Director, on May 20, 2025, at 1:30 p.m., confirmed the required annual and triennial generator testing documentation was not available at the time of the survey.







 Plan of Correction - To be completed: 06/27/2025

Identified generator tests 1. Annual 90-minute load bank test 2. Triennial 4-hour load bank test 3. Annual preventative maintenance and inspection 4. Annual fuel quality test will be completed by a contracted vendor by June 20th, 2025. The Maintenance Director will be educated by the Administrator or designee on K918. Tests will be placed on annual/triennial schedule by the Maintenance Director or designee. Results will be reported to the Quality Assurance and Performance Improvement committee meeting.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of three smoke compartments.

Findings include:

1. Observation on May 20, 2025, at 11:05 a.m., revealed a microwave plugged into a multi-plug adapter in the Director of Nursing's Office.

Interview with the Facility Administrator and Director of Maintenance on May 20, 2025, at 1:30 p.m., confirmed the misuse of a multi-plug adapter being used to power a microwave.










 Plan of Correction - To be completed: 06/27/2025

Multi plug adapter was removed from DON office on May 24th, 2025. Inspection of the administrative offices for extension cords / multi plug adapters will be completed on June 3, 2025. The Maintenance Director will be educated by the Administrator or designee on K920. Audit for extension cords / multi plug adapters will be completed monthly by the Maintenance Director or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.

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