Pennsylvania Department of Health
TOWNE MANOR WEST
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 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.


TOWNE MANOR WEST - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID # 124302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 12, 2024, it was determined that Towne Manor West 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 two-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 provide a carbon monoxide policy per NFPA 720 and PA House Bill 48, affecting the entire facility.

Findings include:

1. Document review on August 12, 2024, at 9:30 a.m., revealed the facility lacked a documented carbon monoxide policy directing staff to conduct the following protocols per the regulations:

A. Introduce fresh air by opening windows and doors, where not a risk to residents.
B. Contact emergency services in accordance with the care facility's written policies.
C. Move residents to nearest source of fresh air.
D. Evacuate if needed, when determined by first responders.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 pm, confirmed carbon monoxide evacuation policy was not available at time of the survey.

2. Document review on April 18, 2023, at 9:35 a.m., revealed the facility failed to adhere to the Care Facility Carbon Monoxide Alarms Standards Act in the following ways:

a) The facility failed to provide documentation showing the carbon monoxide alarms were tested and cleaned per manufacturer's specifications.
b) The facility failed to provide documentation showing the batteries for the carbon monoxide alarms were replaced annually.

Exit interview with the Administrator Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/31/2024

1. Facility will develop carbon monoxide Policy. Carbon monoxide alarms will be tested and cleaned per manufacturer specifications, and batteries changed.
2. Administrator/Designee will reeducate Maintenance Director on maintaining a Carbon Monoxide policy, and cleaning alarms and changing batteries.
3. Maintenance Director/Designee will conducts audits to ensure that a carbon Monoxide policy is in place and that the alarms are tested and cleaned and batteries are checked, Weekly x4 and monthly x3.

NFPA 101 STANDARD Means of Egress - General:

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.

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 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of two levels.

Findings include:

Observation on August 12, 2024, at 12:05 p.m., revealed the doors leading to an enclosed courtyard lacked signage indicating ' Not an Exit ', Community Room on the first floor .

Exit interview with the Administrator and maintenance Regional Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the missing signage.

Refer to NFPA 101.19.2.10.1

Plan of Correction - To be completed: 10/11/2024

1. Signage indicating "NOT AN EXIT" will be placed by first floor Community Room door leading to courtyard.
2. Maintenance Director/Designee will conducts audits to ensure that correct signage is in place for exit doors.
3. Administrator/Designee will reeducate Maintenance Director on maintaining proper signage for exit and non exit doors.

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 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of three levels.

Findings include:

1. Document review on August 12, 2024, at 8:30 a.m., revealed the facility lacked documentation of the following required tests of the battery back-up lighting:

a. monthly 30-second testing.
b. annual 90-minute test.

Exit Interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 10/11/2024

1. Monthly 30 second testing and annual 90-minute testing of battery backup lighting will be conducted.
2. Administrator/Designee will reeducate Maintenance Director on testing battery backup lighting monthly and annually.
3. Maintenance Director/Designee will conducts audits to ensure that battery backup lighting will be tested properly, Monthly x3

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 ensure that exit signs were maintained, affecting the entire facility.

Findings include:

1. Document review on August 12, 2023, at 8:30 a.m., revealed the facility could not produce documentation showing monthly exit sign inspections were conducted as required.

Exit Interview with the Administrator and Maintenance Director on August 12, 2023, at 12:50 p.m., confirmed the missing documentation.

2. Observation on August 12, 2024, at 11:30 a.m., revealed exit signs not illuminated in the following locations:

a. 11:05 a.m., corridor by room 130.
b. 11:20 a.m., lower level by elevator.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the exit sign deficiency.

Plan of Correction - To be completed: 10/11/2024

1. Exit signs outside room 30 and near elevator will be replaced. Monthly exit sign inspection will be conducted.
2. Administrator/Designee will reeducate Maintenance Director on inspecting exit signs monthly.
3. Maintenance Director/Designee will conduct audits to ensure that monthly exit sign inspections will be conducted, monthly x 3

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 the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of two levels.

Findings include:

Observation on August 12, 2024, at 11:40 a.m., revealed, on the first floor electrical transformer room door was propped open with a weighted object.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the propped door.

Plan of Correction - To be completed: 10/11/2024

1. Object obstructing the door to first floor electrical transformer room was removed.
2. Maintenance Director/Designee will conduct audits to ensure that all doors to hazardous areas shall not be propped open.
3. Administrator/Designee will reeducate Maintenance Director on ensuring that all doors to hazardous areas shall not be propped open.
4. Maintenance Director/Designee will conduct audits to ensure that all doors to hazardous areas shall not be propped open, weekly X4 monthly X3.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):

Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser (ABHR), affecting one of two levels.

Findings include:

Observation on August 12, 2024, at 12:05 p.m., revealed an ABHR was installed directly above a duplex electrical outlet, the corridor by room 26, on the first floor.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the ABHR location.

Plan of Correction - To be completed: 10/11/2024

1. Alcohol Based Sanitizer Dispenser in corridor by room 26 was removed.
2. Maintenance Director/Designee will conduct audits to ensure that no Alcohol Based Sanitizer Dispenser are installed directly above electrical outlets.
3. Administrator/Designee will reeducate Maintenance Director on ensuring that no Alcohol Based Sanitizer Dispenser are installed directly above electrical outlets
4. Maintenance Director/Designee will conduct audits to ensure that no Alcohol Based Sanitizer Dispenser are installed directly above electrical outlets, weekly X4 monthly X3.

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

Findings Include:

Observation on August 12, 2024, at 10:45 a.m., revealed the facility fire alarm panel was in trouble mode at time of survey.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 10/11/2024

1. Vendor Tilley Fire was contacted to correct the trouble status from the Fire Alarm System.Tilley inspected the system on 9/13/24 and scheduled a repair for 9/20/24
2. Administrator/Designee will reeducate Maintenance Director on ensuring that the Fire Alarm System is corrected when trouble status is indicated.
3. Maintenance Director/Designee will conduct audits to ensure that no trouble status is indicated on the Fire Alarm System, weekly X4 monthly X3.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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

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

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

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

Findings include:

1. Document review on August 12, 2024, at 9:30 a.m., revealed the June 2024, annual sprinkler inspection report listed the following deficiencies, evidence of corrective action was not available at time of survey:

a. The first tamper in the pit did not function at time of inspection 01/31/24 & 3/19/24 and the fire alarm control panel was in trouble for " Tamper in outside pit input device response too low. This needs to be investigated and repaired. "

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the sprinkler system deficiencies.

2. Document review on August 12, 2024, at 9:30 a.m., revealed the facility could not provide documentation of the following inspections:

a. Second quarter 2024 sprinkler inspection
b. Annual main drain test.
c. Annual control valve.
d. 5-year internal valve and pipe inspection.
e. Semi Annual supervisory switches.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 10/11/2024

1. Vendor Tilley Fire was contacted regarding the issue with the tamper in pit, and regarding the missing inspections, any inspections that were not completed will be scheduled. Tilley came in on 9/13/24 for the 3rd quarter sprinkler inspections as well as the Annual main drain test. The 5-year internal valve and pipe inspection is scheduled for 9/20/24. Tamper was inspected and an engineer is scheduled to come out 9/20/24 to advise on resolution.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that the Fire Alarm System is inspected as per requirements.
3. Maintenance Director/Designee will conduct audits to ensure that the Fire Alarm System inspections are up to date ,monthly X3

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, document review, and interview, the facility failed to maintain the fire resistance rating of smoke barrier separations, affecting the entire facility.

Findings include:

Observation and document review on August 12, 2024, between 8:30 a.m. and 12:00 p.m., revealed smoke barrier walls on the first floor and the on the second floor of the east wing were incomplete near the central bathrooms.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the smoke barrier separations were incomplete.

Plan of Correction - To be completed: 10/11/2024

1. Smoke Barrier walls near central bathrooms on both floors will be completed.
2. Maintenance Director/Designee will conduct audits to ensure that other smoke barriers are intact.
3. Administrator/Designee will reeducate Maintenance Director on ensuring that all smoke barriers are intact.
4. Maintenance Director/Designee will conduct audits to ensure that the smoke barriers will be intact weekly X4 monthly X3

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 observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting two of two levels.

Findings include:

Observations on August 12, 2024, at 10:50 a.m., revealed multiple portable AC units were vented directly above the suspended ceiling, throughout the facility.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the venting.

Plan of Correction - To be completed: 10/11/2024

1. Vendor will be contacted to install alternate HVAC system for hallways.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that AC units are not vented directly into the suspended ceiling.
3. Maintenance Director/Designee will conduct audits to ensure AC units are not vented directly into the suspended ceiling weekly X4 monthly X3

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 institute policies ensuring the proper operation of the facility.

Findings include:

Document review on August 12, 2024, at 9:30 a.m., revealed the facility failed to ensure the means of egress free of obstructions or impediments to full instant use in case of fire or other emergency as required by NFPA 101, section 7.1.10.1 as evidenced by a lack of snow removal policy.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 10/11/2024

1. Facility will develop a Snow Removal Policy.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that a snow removal policy is maintained.
3. Maintenance Director/Designee will conduct audits to ensure that a snow removal policy is maintained weekly X4 monthly X3

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly for two of twelve required drills.

Findings include:

Document review on August 12, 2024, at 9:30 a.m., revealed the facility could not provide documentation that fire drills had been conducted for the following times:

a. Second quarter- Second shift.
b. Third quarter- First shift.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the missing fire drills.

Plan of Correction - To be completed: 10/11/2024

1. Missed fire drill cannot be conducted.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that fire drills will be conducted at least quarterly on each shift.
3. Maintenance Director/Designee will conduct audits to ensure that fire drills will be conducted at least quarterly on each shift, Monthly x3

NFPA 101 STANDARD Electrical Systems - Other:

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 - Component: 01 - Tag: 0911

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

Findings include:

Observations on August 12, 2024, revealed the following electrical system deficiencies:

a. 11:10 a.m., on the second floor, oxygen storage room, open junction box.
b. 11:20 a.m., on the first floor, kitchen cart room, electrical panel missing protective blank.
c. 11:25 a.m., on the first floor, sprinkler/boiler room, electrical panel-EQDP missing protective blank.
d. 11:30 a.m., on the first floor, sprinkler/boiler room, 3- open junction boxes.
e. 11:35 a.m., on the first floor, laundry behind dryers, open junction box.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the electrical deficiencies.

Plan of Correction - To be completed: 10/11/2024

1. Junction boxes will be covered and protective blanks will be installed.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that junction boxes are closed and breaker panels contain protective blanks.
3. Maintenance Director/Designee will conduct audits to ensure that junction boxes are closed and breaker panels contain protective blanks. weekly x4, Monthly x3

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 required testing of emergency generator components, affecting the entire facility.

Findings Include:

Document review on August 12, 2024, at 8:30 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a.Weekly inspection and visual
b.Weekly inspection battery electrolyte levels or battery voltage
c.Monthly testing battery electrolyte specific gravity or conductance testing
d.Monthly 30 minute load test
e.Operate transfer switches
f.Diesel generator PM
g.3-year 4-hour load test

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 10/11/2024

1. Vendor Genserve was contacted regarding the PM, they were here for the semi annual PM checklist on 4/19/24, are due to return by10/10/24. The 4 hour load test was last done 12/3/2021 they are due to return by 10/10/24. Weekly and monthly inspections and tests on generator and battery will be conducted.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that generator system will be inspected and tested properly according to requirements.
3. Maintenance Director/Designee will conduct audits to ensure that generator system will be inspected and tested properly according to requirements. weekly x4, Monthly x3

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 - Component: 01 - Tag: 0920

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

Findings include:

Observations on August 12, 2024, revealed the following electrical deficiencies:

a. 10:50 a.m., on the second floor, Dietary Manager Office- fridge plugged into power strip.
b. 11:00 a.m. - 12:30 p.m., Numerous portable AC units throughout the facility were powered with extension cords. The extension cords were strewn above the ceiling, staggered along walls, around doors, and into resident rooms, some were run outside the facility and into resident rooms.

Exit interview with the Administrator and Maintenance Director on August 12, 2024, at 12:50 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 10/11/2024

1. Extension cords were removed. Vendor ABM electric was contacted regarding issues with power causing breakers to trip leading to the need for power strips and extension cords, service was completed.
2. Administrator/Designee will reeducate Maintenance Director on ensuring that power strips and extension cords are not used in place of permanent wiring.
3. Maintenance Director/Designee will conduct audits to ensure that power strips and extension cords are not used in place of permanent wiring, weekly x4, Monthly x3

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