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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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.


GWYNEDD 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 January 24, 2024, it was determined that Gwynedd Healthcare 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(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 document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.
Findings include:

Document review on January 24, 2024, at 10:56 a.m., revealed the facility failed to conduct a full scale emergency preparedness exercise, within the previous year, followed by an exercise evaluation and necessary policy changes.

Exit interview with the Administrator and Maintenance Supervisor, confirmed the Emergency Preparedness Plan did not include the above item.

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

1. The facility will conduct a full-scale emergency preparedness exercise and will evaluate and make any policy changes if necessary.
2. The facility will complete monthly audits to ensure that a full-scale emergency preparedness exercise was completed yearly.
3. Audits will be reviewed monthly x3 at QAPI to ensure compliance

Initial comments:Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0000

Facility ID# 075002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 24, 2024, it was determined that Gwynedd Healthcare And Rehabilitation Center 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 II (000), unprotected non-combustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0100

Based on document review and interview, the facility failed to maintain carbon monoxide detectors in accordance with PA Act #48, for three of three carbon monoxide detectors.

Findings include:

Document review on January 24, 2024, at 9:45 a.m., revealed the facility lacked documentation to illustrate the battery replacement was being conducted annually.

Exit Interview with the Administrator and the Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above battery-operated carbon monoxide detectors documentation was not available.

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

1. The facility will ensure that cardon monoxide detectors are maintained and will have documentation to illustrate the battery replacement is being conducted annually.
2. Facility has added a task to our TELS system to generate a work order to change carbon monoxide detector batteries every six months.
3. The Maintenance Director will ensure completion of this task and report his findings to QAPI

NFPA 101 STANDARD Means of Egress - General:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0211

Based on observation, document review and interview, it was determined the facility failed to maintain acceptable exit access, affecting one of two levels from the facility.

Findings include:

Observation and document review on January 24, 2024, at 12:20 p.m., revealed headroom inside the basement-level stairwell enclosure, from the stair tread to the overhead obstruction, was less than the required minimum six feet eight inch clearance. The stairwell provides one of two recognized means of egress from the basement.

Exit interview with the Administrator and Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the basement level exit access deficiency.

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

The facility would like to use the FSES on file

NFPA 101 STANDARD Emergency Lighting:

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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to ensure emergency lighting was tested annually for three of three emergency lights.

Findings include:

Document review on January 24, 2024, at 10:45 a.m., revealed the facility could not produce documentation showing a 90-minute annual test was performed over the past 12 months for their emergency lighting. The facility communicated that they were no longer needed but the lights were still in place in the kitchen and the front office area at the time of the survey.

Exit interview with the Administrator and Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above deficiencies existed.

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

1.The facility's emergency lighting has been removed from the kitchen and the front office area since the facility is powered by a full-service generator.
2. The Maintenance Director completed an audit and no other emergency lights in the building were noted.

NFPA 101 STANDARD Exit Signage:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signs on two of two levels.

Findings include:

Observation on January 24, 2024, between 11:28 a.m. and 12:21 p.m., revealed the following emergency exit sign deficiencies:
A. (11:28 a.m.) A-Wing lounge, door to the outside lacked "Not An Exit" sign;
B. (12:00 p.m.) Garden lounge, two doors to the courtyard lacked "Not An Exit" sign;
C. (12:21 p.m.) Basement exit light lacked continuous illumination.

Exit interview with the Administrator and the Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above emergency exit sign deficiencies existed.

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

1. The Maintenance Director/Designee has placed not an exit sign on the noted areas, A wing Lounge door and both the sliding glass doors in the garden lounge. The basement exit light is now illuminated as batteries were changed.
2. Audits will be completed monthlyx3 then quarterly x4 to ensure that not exit an sign are posted where they need to be and that the exit lights throughout the facility are illuminated.
3. The Maintenance Director has in serviced his staff on the daily rounds sheet that has a exit light checklist on it to complete properly and immediately change a burned out bulb and to ensure that exit signs are posted.
4. Audits will be reviewed monthly x3 at QAPI to ensure compliance.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to maintain annual inspections and maintenance of the fire alarm system affecting the entire building.

Findings include:

Document review on January 24, 2024, at 10:03 a.m., revealed the facility annual fire alarm report (dated July 31, 2023) indicated the following deficiencies and the facility could not provide documentation showing corrections were made at the time of the survey:
A. "Smoke detector in room C16 failed to report to FACP device did test properly upon a second attempt. Device was dirty still recommend replacing it."
B. "FACP phone lines in and out of trouble during inspection. Panel reading UDACT trouble upon arrival outside technician on site during inspection to troubleshoot issue."
C. "Multiple conventional 135 FROR heat detectors that have been discontinued on site and need to be upgraded per NFPA 72."
D. "Smoke detectors in administration wing failed to report to FACP."
E. "SD In room A6 failed to report to FACP. Device did test properly upon second attempt. Device was dirty still recommend replacing it."

Exit interview with the Administrator and the Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above deficiencies existed at the time of the survey.

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

1. Facility has contacted our contracted alarm inspection company to provide appropriate documentation that areas identified were corrected.
2. Moving forward the maintenance director/designee will ensure that any repairs or deficiencies that are identified are marked as being corrected/repaired.

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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0353

Based on document review, observation, and interview, the facility failed to maintain, inspect, and test fire sprinkler systems in one of four annual quarters.

Findings include:

1. Document review on January 24, 2024, at 10:35 a.m., revealed the facility lacked documentation to indicate that a quarterly test of the fire sprinkler system was performed during the first quarter of 2023.

Exit interview with the Administrator and Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above fire sprinkler inspection was not on-site during the time of the survey.
2. Observation on January 24, 2024, at 12:15 p.m., revealed basement, housekeeping room, had two sections (approximately 4' X 5' and 1' X 2') of damaged ceiling from a recent water leak. The damaged sections of ceiling can cause a delay in the activation of the sprinkler heads.
Exit interview with the Administrator and Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above areas were damaged.

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

1. Facility will ensure that quarterly tests of the fire sprinkler system are completed. Facility will ensure that the damaged ceiling in the basement areas identified are repaired.
2. Maintenance Director/Designee will complete monthly audits to ensure that quarterly tests of the fire sprinkler system are completed and that damaged ceilings from water damage are repaired.
3. Audits will be reviewed monthly x3 at QAPI to ensure compliance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0372

Based on document review and interview, it was determined that the facility failed to test and inspect the fire, ceiling, and smoke dampers throughout the building, within the previous six years, per NFPA 101-8.5.5.4.2 and NFPA 105-6.5.2.

Findings include:

Document review on January 24, 2024, at 10:10 a.m., revealed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Exit interview with the Administrator and the Maintenance Supervisor January 24, 2024, at 1:00 p.m., confirmed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

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

1. The dampers throughout the facility have been tested and inspected by an outside contractor.
2. Maintenance Director/Designee will ensure that the dampers will be inspected and tested every 6 years.

NFPA 101 STANDARD Electrical Systems - Other:

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.

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in three of over twenty rooms.

Findings include:

Observation on January 24, 2024, between 12:11 p.m. and 12:41 p.m., revealed the following electrical deficiencies:
A. (12:11 p.m.) Brief room, had a junction box that was missing the cover plate;
B. (12:36 p.m.) Kitchen, had a section of flexible conduit separating from the junction box connection;
C. (12:41 p.m.) Main dining room, had a receptacle that was not securely mounted and was hanging by the wires located under the PTAC unit.

Reference: NFPA 70-314.17, NFPA 70-314.28 (C), and NFPA 300.11

Exit interview with the Administrator and Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above electrical system deficiencies.

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

1. The brief room missing cover plate over junction box has been installed. The flexible conduit in the kitchen under the tray line has been repaired. The receptacle in the main dining room has been secured.
2. The Maintenance Director/Designee will complete an audit to ensure that junction boxes are not missing a covered plate, that flexible conduits are in good condition, and that receptacles are secure throughout the facility.
3. Random audits will be completed weeklyx4 then monthlyx3 to ensure compliance.
4. Audits will be reviewed monthly x3 at QAPI to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator.

Findings include:

Document review on January 24, 2024, at 9:31 a.m., revealed the emergency generator testing reports did not include the monthly battery electrolyte-specific gravity or conductance testing.

Exit interview with the Administrator and Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the generator testing reports lacked the above item.

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

1. A conductivity tester for the generator battery has been purchased and conductivity testing will be completed monthly by the Maintenance Director/Designee.
2. An audit will be completed monthly x3 by the Maintenance Director/Designee to ensure that monthly testing of the generator is being completed.
3. Audits will be reviewed monthly x3 at QAPI to ensure compliance.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical equipment on two of two building levels.

Findings include:

1. Observation on January 24, 2024, between 12:06 p.m. and 12:32 p.m., revealed the following electrical equipment deficiencies:
A. (12:06 p.m.) Laundry room, had a surge protector plugged into a surge protector with powering various items;
B. (12:19 p.m.) Basement, maintenance office, had two extension cords being used to power battery charging equipment;
C. (12:21 p.m.) Basement, electrical room, had an extension cord being used to power the facility cable television equipment.
D. (12:32 p.m.) Kitchen, had a three-way plug adapter in use.

Exit interview with the Administrator and the Maintenance Supervisor on January 24, 2024, at 1:00 p.m., confirmed the above electrical cord deficiencies.

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

1. The surge protector plugged into the surge protector, the extension cords and the three-way plug identified during the inspection were immediately removed.
2. Education will be completed by the Maintenance Director/Designee to ensure that staff are aware that extension cords and three-way plugs cannot be used.
3. Random audits will be completed weekly x3 then monthlyx4 to ensure that surge protectors are not plugged into surge protectors, extension cords are not sued, and that3 way plugs are not being used.
4. Audits will be reviewed monthly x3 at QAPI to ensure compliance.

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