Pennsylvania Department of Health
COMPLETE CARE AT HARSTON HALL LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 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.


COMPLETE CARE AT HARSTON HALL LLC - 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 1, 2025, it was determined that Complete Care ar Harston Hall 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 document review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility established and maintaining a comprehensive emergency preparedness program that meets the requirements. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and updated at least annually weekly x2 then monthly x2. All findings will be brought to QAPI for review.

403.748(a)(3), 416.54(a)(3), 418.113(a)(3), 441.184(a)(3), 482.15(a)(3), 483.475(a)(3), 483.73(a)(3), 484.102(a)(3), 485.542(a)(3), 485.625(a)(3), 485.68(a)(3), 485.727(a)(3), 485.920(a)(3), 491.12(a)(3), 494.62(a)(3) STANDARD EP Program Patient Population:

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.

§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).

[(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 the following:]

(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*[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. The plan must do all of the following:
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Observations:
Name: - Component: -- - Tag: 0007

Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the Facility's Emergency Preparedness Plan did include policies and procedures that addressed persons at-risk, affecting the entire facility.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

The facility will ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility.
Facility updated Emergency Preparedness Plan to include policies and procedures that addressed persons at-risk, affecting the entire facility.

403.748(b)(5), 416.54(b)(4), 418.113(b)(3), 441.184(b)(5), 482.15(b)(5), 483.475(b)(5), 483.73(b)(5), 484.102(b)(4), 485.542(b)(5), 485.625(b)(5), 485.68(b)(3), 485.727(b)(3), 485.920(b)(4), 486.360(b)(2), 491.12(b)(3), 494.62(b)(4) STANDARD Policies/Procedures for Medical Documentation:

§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Observations:
Name: - Component: -- - Tag: 0023

Based on document review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed facility failed to develop Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility developed Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and preserves patients information and confidentiality at least annually weekly x2 then monthly x2. All findings will be brought to QAPI for review.

403.748(c)(7), 416.54(c)(7), 418.113(c)(7), 441.184(c)(7), 482.15(c)(7), 483.475(c)(7), 483.73(c)(7), 484.102(c)(6), 485.542(c)(7), 485.625(c)(7), 485.68(c)(5), 485.727(c)(5), 485.920(c)(7), 491.12(c)(5), 494.62(c)(7) STANDARD Information on Occupancy/Needs:

§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).

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

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, it was determined the facility's emergency preparedness communication plan did not include a means of providing information about the ASC's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility's emergency preparedness communication plan did not include a means of providing information about the ASC's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

The facility's emergency preparedness communication plan will include a developed means of providing information about the LTC needs and its ability to help the authority having jurisdiction, the Incident Command Center, or designee. The facility will update EP Book and add it to QAPI for review.

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:

§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, it was determined the facility failed to conduct the Emergency Plan's required annual-full scale exercise or accepted substitution and the required additional exercise or accepted substitution, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility failed to conduct an annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution within the previous 12 months.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

The facility will conduct the Emergency Plan's required annual-full scale exercise, a mock disaster drill and a tabletop exercise affecting the entire facility. These will be done within the next 2 months. NHA will audit monthly x2, results will be brought to QAPI for review.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 080702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 1, 2025, it was determined that Complete Care at Harston Hall, LLC was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, 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 - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to update facility policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility failed to adhere to the Care Facility Carbon Monoxide Alarms Standards Act in the following ways:

a. The facility lacked a Carbon Monoxide Evacuation Plan.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility will update facility policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility. The facility will develop a Carbon Monoxide Evacuation Plan and add it to the EPP book.

NFPA 101 STANDARD Egress 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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the fcaility failed to maintain doors with Special Needs Locking Arrangements, affecting one of three levels in the facility.

Findings include:

Observation on May 1, 2025, at 10:08 a.m., revealed, on the first floor, in the Physical Therapy, the staff did not know the code to unlock the Exit Door.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the staff did not know the unlock code.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain doors with Special Needs Locking Arrangements, affecting all of three levels in the facility.
The Director of Maintenance will in-service the Physical Therapy department on the codes on all doors.

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 and inspect emergency lighting, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Monthly testing;
b. Annual 90 minute testing.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain and inspect emergency lighting, affecting the entire facility.
Director of Maintenance or designee will audit emergency lighting of at least 1-1/2-hour duration, monthly testing for 30 seconds and annual 90-minute testing weekly x4 then monthly x2. All findings will be brought to QAPI for review.

NFPA 101 STANDARD Exit Signage:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain and inspect exit signs, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility failed to provide documentation of monthly exit sign inspection.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain documentation of monthly exit sign inspection.
NHA or designee will audit weekly x4 then monthly x2. All findings will be brought to QAPI for review.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas, affecting one of two levels in the facility.

Findings include:

Observation on May 1, 2025, at 9:51 a.m., revealed, on the second floor, in the Kitchen, the Storage Closet next to the Janitor's Closet lacked a self-closer.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of self-closer.

Plan of Correction - To be completed: 06/10/2025

Facility will maintain hazardous areas, affecting all of two levels in the facility.
Maintenance will audit all self closers for proper use weekly x2, then monthly x2. Results will be brought to QAPI for review.
Door self closer was ordered and installed for proper use.

NFPA 101 STANDARD Cooking Facilities:

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 document review, observation, and interview, it was determined the facility failed to maintain and inspect the kitchen exhaust hood suppression system, affecting the entire facility.

Findings include:

1. Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Semi-annual kitchen exhaust hood suppression system maintenance and testing within 6 months after 5/29/24;
b. Semi-annual kitchen exhaust hood cleaning within 6 months prior to 3/20/25.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

2. Observation on May 1, 2025, at 9:52 a.m., revealed the kitchen hood exhaust suppression system lacked monthly inspections.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of inspections.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain and inspect the kitchen exhaust hood suppression system, affecting the entire facility. Contracted service called for updated visit and servicing the Semi-annual kitchen exhaust hood suppression system maintenance and testing within 6 months after and will be coming out the week of 5/29/24. They will also complete a cleaning.
Director of Maintenance will audit monthly x2, to ensure systems are checked and in place. Results will be brought to QAPI for review. Life Safety book will be updated

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 - Component: 01 - Tag: 0345

Based on document review, observation, and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on May 1, 2025, at 8:15 a.m., revealed the facility was lacking documentations of the following tests and inspections:

a. Annual and semi-annual fire alarm system testing;
b. Smoke detector sensitivity testing within the past 2 years.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

2. Observation on May 1, 2025, at 9:41 a.m., revealed the fire alarm panel was in a trouble state.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the fire alarm panel was in a trouble state.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain and inspect the fire alarm system, affecting the entire facility. Outside contracted service was called to complete the Annual and semi-annual fire alarm system testing and Smoke detector sensitivity testing within the past 2 years. Outside company called to inspect fire panel for service and or replace. The Director of Maintenance or will audit fire alarm systems 2x weekly for 2 monthly. All findings will be brought to QAPI for review. Any issues arise, outside company notified.

NFPA 101 STANDARD Fire Alarm System - Out of Service:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0346

Based on document review and interview, it was determined the facility failed to provide required policies, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide a fire watch policy.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility will maintain a fire watch policy and update in EP book. The Director of Maintenance will audit EP book for updated policies 2x weekly for 2 monthly. All findings will be brought to QAPI for review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Quarterly sprinkler inspections for the 1st quarter of 2025 and the 4th quarter of 2024;
b. 5 year internal valve and pipe inspection.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain and inspect the sprinkler system, affecting the entire facility. Outside contracted service called and scheduled for quarterly sprinkler inspection and 5 year internal valve and pipe inspection.
The Director of Maintenance or designee will audit inspect sprinkler systems 2x weekly for 2 monthly. All findings will be brought to QAPI for review.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide a copy of the fire extinguisher technician's certification that conducted the annual fire extinguisher maintenance.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility received a copy of the fire extinguisher technician's certification that conducted our annual fire extinguisher maintenance. Copy was update in EP book.
The Director of Maintenance or designee will audit certifications monthly x2. All findings will be brought to QAPI for review.

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 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of three levels in the facility.

Findings include:

Observation on May 1, 2025, at 9:58 a.m., revealed, on the second floor, the smoke barrier near resident room 216 was blocked open by a patient lift.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the blocked open smoke barrier door.

Plan of Correction - To be completed: 06/10/2025

The facility will maintain the fire resistance of smoke barriers, affecting all of three levels in the facility. Blockage was removed.
Staff in-serviced on the importance of keeping the smoke barrier doors free from any items. The Director of Maintenance or designee will audit smoke barrier doorways 3x weekly for 2 monthly. All findings will be brought to QAPI for review.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

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

Findings include:

1. Observation on May 1, 2025, at 10:00 a.m., revealed, on the second floor, a non-GFCI outlet located within 6 feet of a sink in the Mechanical Room. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6ft of the outside edge of the sink.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the non-GFCI outlet installed within 6 feet of a utility sink.

2. Observations on May 1, 2025, between 9:39 a.m. and 9:50 a.m., revealed storage within three feet of the electrical panels in the below locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

a. 9:39 a.m., on the third floor, Mechanical Room;
b. 9:45 a.m., on the third floor, next to Clean Linen;
c. 9:50 a.m., on the second floor, next to Clean Linen.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the improper storage in front of the electrical panels.

3. Observation on May 1, 2025, at 9:43 a.m., revealed, on the third floor, an unsecured junction box above the smoke barrier next to resident room 312.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the unsecured junction box.

Plan of Correction - To be completed: 06/10/2025

1: outlet was change to a GFCI over the sink
2: storage was removed from the room

National Electric Code, for electrical wiring and equipment, affecting two of three levels in the facility.
- a. 9:39 a.m., on the third floor, Mechanical Room;
Box was removed and in-serviced staff on the importance of keeping that area free from items
b. 9:45 a.m., on the third floor, next to Clean Linen;
wheelchair was in the cubby hole was removed and staff in-serviced staff on the importance of keeping that area free from items
c. 9:50 a.m., on the second floor, next to Clean Linen.
wheelchair was in the cubby hole /chair removed and staff in-serviced staff on the importance of keeping that area free from items
unsecured junction box above the smoke barrier next to resident room 312 was fixed and secured.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain HVAC systems, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide documentation that the fire/smoke dampers had been tested/exercised within the past 4 years.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility will provide documentation that the fire/smoke dampers had been tested/exercised within the past 4 years. Outside company called for service to complete testing and update EP book.
NHA will audit EP book monthly x2 for documentation. Results will be reviewed in QPAI.

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

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of trash chutes, affecting one of three levels in the facility.

Findings include:

Observation on May 1, 2025, at 9:55 a.m., revealed, on the second floor, the trash chute door failed to close and latch.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the door failed to close and latch.

Plan of Correction - To be completed: 06/10/2025

on the second floor, the trash chute door was fixed and is able to close and latch. It was clean and clear of debris.
Staff in-serviced on the importance to keep it clean and free from debris.
The Director of Maintenance or designee will audit trash chute 3x weekly for x2 monthly. All findings will be brought to QAPI for review.

NFPA 101 STANDARD Operating Features - Other:

Operating Features - Other
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features 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 in Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0700

Based on document review and interview, it was determined the facility failed to provide required policies, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide the following policies:

a. Snow removal;
b. Fire evacuation.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

Facility will provide required policies, snoke removal and fire evacuation affecting the entire facility. Snow removal contract was received, and the fire evacuation was completed and updated in the EP book.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on May 1, 2025, at 8:15 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Weekly inspection of battery voltage;
b. Monthly testing of battery conductance;
c. Monthly testing of the generator under load;
d. Monthly operation of the ATS;
e. Annual 90 minute load bank;
f. Preventative maintenance indicating no evidence of wet stacking.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 06/10/2025

facility will maintain and inspect the emergency generator, affecting the entire facility

a. Weekly inspection of battery voltage was completed. Maintenance Director will audit weekly x4 then monthly x2
b. Monthly testing of battery conductance was completed. Maintenance Director will audit weekly x4 then monthly x2
c. Monthly testing of the generator under load was completed. Maintenance Director will audit weekly x4 then monthly x2
d. Monthly operation of the ATS was completed. Maintenance Director will audit weekly x4 then monthly x2
e. Annual 90 minute load bank was completed. Maintenance Director will audit weekly x4 then monthly x2
f. Preventative maintenance of wet stacking was completed by Powerhouse Company. All documents are added to our Life Safety Book

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage areas for gas cylinder storage over 3,000 cubic feet.

Findings include:

Observation on May 1, 2025, at 10:30 a.m., revealed, on the first floor, the Conference Room was being used to store approximately 72 E sized oxygen tanks. The room lacked a 1 hr. fire resistance rating.

Exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., confirmed the improper storage of oxygen tanks.

Plan of Correction - To be completed: 06/10/2025

Facility will maintain storage areas for gas cylinder storage over 3,000 cubic feet.

Oxygen bottles were removed from the conference room and relocated to the Oxygen room. Staff in-service on the proper location of the oxygen bottles. The Director of Maintenance or designee will audit Oxygen bottle location 3x weekly for 2 monthly. All findings will be brought to QAPI for review.

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