Pennsylvania Department of Health
TOWNE MANOR EAST
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TOWNE MANOR EAST
Inspection Results For:

There are  42 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 EAST - 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 February 8, 2024, it was determined that Towne Manor East 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, it was determined the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan, affecting the entire facility.

Findings include:

Document review on February 8, 2024, at 8:15 a.m., revealed the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan within the previous 12 months.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the lack of required exercises.




 Plan of Correction - To be completed: 03/15/2024

OBSERVATION #39:
1. The facility will complete a facility-based exercise of the facility disaster plan. The exercise will include facility staff, the medical Director, the Pharmacy Consultant, the Plant Consultant and Community Partners in transportation and healthcare. The facility will register to attend the next available community-based tabletop exercise class for Disaster Preparedness. The next Tabletop Community Exercise through the SE Pennsylvania Healthcare Coalition is April 23, 2024.
2. The Executive Director/ designee will monitor for compliance via attendance at the Facility-based disaster plan exercise. The Executive Director will review registration documentation for the April 23rd, 2024 Community-based exercise.

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


Facility ID# 125102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 8, 2024, it was determined that Towne Manor East 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 (000), unprotected non-combustible construction, 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 accurate, portable floor plans as required, affecting the entire facility.

Findings Include:

Document review on February 8, 2024, at 8:15 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed accurate floor plans were not available.




 Plan of Correction - To be completed: 03/15/2024

K100 NFPA 101 General requirements – Other 'C'
1. The facility obtained the required floor plans indicating smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, medical gas rooms, required exits and shaft walls. The floor plans have been laminated and posted on each floor.
The Maintenance Director received education from the Executive Director on the requirement that the facility maintain Life Safety Code floor plans for each floor indicating smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, medical gas rooms, required exits and shaft walls.
Staff were educated on the location of the Life Safety floor plans.
2. The Executive director will conduct random rounds weekly to ensure the Life Safety floor plans are laminated and posted on each floor.
Results of the audits will be brought to the Quality Assessment and Assurance Compliance Meeting weekly x4 and monthly x6.

NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.

Findings include:

Document review on February 8, 2024, at 8:15 a.m., revealed the facility has been classified as a three story, Type II (000), unprotected non-combustible construction, that is fully sprinklered. The story height exceeds the maximum allowance by two stories.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the building height exceeded the maximum allowed.





 Plan of Correction - To be completed: 03/15/2024

K161 NFPA 101 Building Construction Type and Height
1. An FSES (Fire Safety Evaluation System) was completed for each of the facility's three floors. The FSES describes the construction, the number of stories, including basement, floors on which patients are located and date of approval. The Life Safety Code floor plans are attached to the FSES. Copies of the FSES and copies of the Life Safety floor plans have been provided to the Norristown Field Office for review.
Annually in January, the Physical Plant Consultant / designee will complete an FSES for each of the facility's three floors. The FSES will be maintained in the facility's Life Safety binder for review and updated annually.
2. The Executive Director will monitor for compliance via weekly review of the FSES (Fire Safety Evaluation System) located in the facility Life Safety binder. The audit will ensure that the FSES describes the construction, the number of stories, including basement, floors on which patients are located, location of the smoke and fire barriers and date of approval and the attachment of the Life Safety Code facility floor plans.
Results of the audits will be brought to the Quality Assessment and Assurance Compliance Meeting weekly x4 and monthly x6.

NFPA 101 STANDARD Cooking Facilities: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.
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 and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting two of four inspections.

Findings include:

1. Document review on February 8, 2024, at 8:15 a.m., revealed the facility could not produce documentation of a semi-annual kitchen hood suppression system inspection within 6 months of 3/2/2023.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the lack of documentation.


2. Document review on February 8, 2024, at 8:15 a.m., revealed the facility could not produce documentation of a semi-annual kitchen hood cleaning within 6 months of 6/7/2023.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the lack of documentation.




 Plan of Correction - To be completed: 03/15/2024

K 324 NFPA 101 Cooking Facilities

1.The kitchen hood suppression system 6-month inspection has been scheduled with the vendor.
The kitchen hood 6-month cleaning has been scheduled with the vendor.
The Executive Director provided education to the Maintenance Director that every 6 months the kitchen hood suppression system must be inspected, and the kitchen hood must be professionally cleaned.
An annual calendar January – December has been set in the Life Safety binder with a highlighted schedule of when the kitchen hood suppression system shall be inspected and when the kitchen hood shall be cleaned by the vendor.
2. The Executive Director / designee shall audit the facility's Life Safety binder weekly to ensure compliance with the calendar, that vendors are contacted, and the 6-month suppression system inspections and 6-month kitchen hood cleanings are completed timely. Findings of the audits will be reviewed at the Quality Assessment and Assurance Compliance Meeting weekly x4 and monthly x6.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
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:

1. Document review on February 8, 2024, at 8:15 a.m., revealed the facility could not produce documentation of a second and third quarter sprinkler inspection.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the lack of documentation.


2. Observation on February 8, 2024, at 10:57 a.m., revealed, in the ground floor Laundry, excessive debris on the sprinklers.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the excessive debris on the sprinklers.


3. Observation on February 8, 2024, at 11:04 a.m., revealed, in the ground floor Maintenance Director Office, a sprinkler was missing an escutcheon.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the missing sprinkler escutcheon.




 Plan of Correction - To be completed: 03/15/2024

K 353 Sprinkler System - Maintenance and Testing
1. In an abundance of precaution, the facility scheduled a sprinkler inspection with the vendor. This is in addition to the quarterly sprinkler test.
An annual calendar January – December has been set in the Life Safety binder with a highlighted schedule of when the sprinkler system shall be inspected, quarterly by the vendor.
The laundry sprinkler was cleaned of debris.
The escutcheon cup missing on the basement sprinkler was replaced.
The Executive Director educated the Maintenance Director on the requirement that sprinkler inspections be conducted quarterly. The results of those inspections be placed in the facility Life Safety binder. Further education was provided on the requirement that sprinklers remain free of debris and each sprinkler should have an escutcheon cup protecting the sprinkler.
2. Weekly, the Executive Director / designee will randomly audit sprinkler heads to ensure they are free from debris and have escutcheon cups for protection. The Executive Director / designee will review the facility Life Safety binder to ensure quarterly sprinkler inspections are completed timely. Results of audits will be discussed at the Quality Assessment and Assurance Compliance Meeting weekly x4 and monthly x6.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 observation and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings include:

Observations on February 8, 2024, between 10:38 a.m. and 11:05 a.m., revealed portable fire extinguishers missing monthly inspections in the following locations:

a. 10:38 a.m., on the second floor, Activities Office;
b. 10:50 a.m., on the first floor, fire extinguisher across from resident room 118;
c. 11:05 a.m., on the ground floor, Personal Care.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the lack of monthly inspections.






 Plan of Correction - To be completed: 03/15/2024

K 0355 Portable Fire Extinguishers
1.The fire extinguishers in the second-floor activities office, on the first floor across from room 118 and the fire extinguisher in Personal Care were inspected by the Maintenance Director at the time of the survey exit and found to be operational affixing his initials to validate.
The Executive Director provided education to the Maintenance Director that all fire extinguishers in the facility need to be inspected monthly and validate that inspection on the fire extinguisher inspection card attached with his / her initials.
An inventory of all fire extinguishers in the building shall be maintained in the facility Life Safety binder.
A full-house inspection of all fire extinguishers in the facility was completed by the Maintenance Director and the NHA on February 9th and 10th. No further issues noted.
2. Weekly, the Executive Director / designee shall randomly audit fire extinguishers in the facility to ensure they are operational in a safe manner.
Results of audits will be discussed at the Quality Assessment and Assurance Compliance Meeting weekly x4 and monthly x6.

NFPA 101 STANDARD Utilities - Gas and Electric:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




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

Based on observation and interview, it was determined the facility failed to maintain protection for electrical wiring and equipment, affecting one of three levels in the facility.

Findings include:

Observation on February 8, 2024, at 11:07 a.m., revealed on the ground floor, in the Elevator Machine Room, the cover was not installed on the elevator controls.

Exit interview with the Administrator and Maintenance Director on February 8, 2024, at 11:15 a.m. confirmed the lack of elevator control cover.




 Plan of Correction - To be completed: 03/15/2024

K 511 NFPA 101 Utilities – Gas and Electric

1. The cover panel was installed over the elevator controls at the time of the survey.
The Executive Director provided education to the Maintenance Director that the cover must be installed over the elevator control box to maintain protection for the electrical wiring and equipment. Other areas of the facility with electrical wires and equipment will be audited weekly by the Maintenance Director.
2. Weekly, the Executive Director / designee will audit the elevator cover panel and other equipment areas requiring a cover panel to provide protection to the electrical wires and equipment.
Results of audits will be discussed at the Quality Assessment and Assurance Compliance Meeting weekly x4 and monthly x6.


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