Nursing Investigation Results -

Pennsylvania Department of Health
SILVER LAKE CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SILVER LAKE CENTER
Inspection Results For:

There are  32 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.
SILVER LAKE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 28, 2020, at Silver Lake Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID # 131902
Component 01
Main building 01

Based on a Medicare/Medicaid Recertification Survey completed on January 28, 2020, it was determined Silver Lake Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two story, Type II (000), unprotected non-combustible construction, with a basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress Requirements - Other: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 Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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.
18.2, 19.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200

Based on observation and interview, it was determined the facility failed to maintain the means of egress accessible at all times, in three instances, affecting three of four smoke compartments.

Findings Include:

1. Observation on January 28, 2020, at 12:10 p.m., revealed the egress gate from the exterior smoking area could not be opened at the time of inspection, near the recreation room, 1st floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed exit gate was obstructed from opening.


2. Observation on January 28, 2020, at 1:30 p.m, revealed there was storage (boxes, mattresses, etc.) housed in the corridor, obstructing egress to the exterior (exit discharge) door from the basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the obstructions to egress.


3. Observation on January 28, 2020, at 1:45 p.m., revealed there items stored in the corridor means of egress at room three to room 11 (food carts, table, lift, linen cart, chair, blood pressure monitor, and three wheelchairs), obstructing the means of egress on both sides of the corridor, 1st floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed there were obstructions to egress.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Gate was repaired and reprogrammed on 01/28/2020, boxes, mattresses and any other items in the corridors, obstructing egress were removed.

Items stored in the corridor means of egress at room 3 to room 11 were removed

All other corridors were checked to ensure they were egress accessible and found no issues

Staff will be educated by maintenance Director/designee on making sure means of egress throughout the building remain accessible at all times.

Maintenance Director / Designee will do audits of corridors and the gate 2x week for four weeks, 2x a month for two months and as needed thereafter to ensure they are always egress accessible.

Results will be reported to QA for further review and recommendations.

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 facility failed to maintain Special Locking Arrangements (SLA's) in operable condition, in one instance, affecting one of four smoke compartments.

Findings Include:

1. Observation on January 28, 2020, at 1:46 p.m., revealed the SLA at the exit door outside room 11 did not release when tested.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the locking arrangement was not operable.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Special Locking Arrangements at the exit door outside room 11 was repaired on 1/29/2020

All other like doors were checked, and no issues found

Maintenance Director / Designee will do audits of the 5 random doors per week x 4weeks and 10 random doors per month for 2 months and thereafter as needed to make sure that locking arrangements for the doors are operable.

Results of the audits will be reported to QA for further review and recommendations

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting three of three levels.

Findings Include:

1. Observation on January 28, 2020, between 12:15 p.m. and 3:30 p.m, revealed labels verifying the fire rating of stair tower door frames could not be found at the time of inspection.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the fire resistance rating of the stair enclosures could not be determined.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Stair tower door frames fire rating will be recertified and labels verifying the fire rating will be replaced

All other door frames were inspected to make sure they are certified and the fire rating labels were on and no issues noted

Maintenance Director / designee will do audits of 2 random fire doors 1x a week x 4 weeks, 5 random fire doors a month for two months and as needed thereafter.

Results will be reported to QA for further review and recommendations

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 smoke resistant separations from hazardous areas (in sprinklered locations), affecting two of four smoke compartments.

Findings Include:

1. Observation on January 28, 2020, at 1:04 p.m., revealed the bio-hazard room corridor door across from room 229 would not positively latch into its frame when tested, 2nd floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the hazardous area lacked smoke tight separation.


2. Observation on January 28, 2020, at 1:30 p.m, revealed there was storage (boxes, mattresses, etc.) housed in the corridor within the basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed combustible materials were stored in the corridor means of egress.


3. Observation on January 28, 2020, at 1:30 p.m., revealed the central supply storage room door self-closure had been disconnected, basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the hazardous area lacked a smoke tight separation.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Bio- hazard room corridor door across from room 229 was repaired to make sure it latches by replacing the closure, combustible materials were removed from the corridor and the central supply storage room door self- closure has been repaired.

All other like areas were inspected and found to be in compliance

Maintenance Director will be educated by the Administrator/ Designee on making sure hazardous areas are protected by a fire barrier, doors shall be self-closing or automatic closing.

Maintenance Director / designee will do audits of all hazardous areas two x a week x 4 weeks, two times a month for two months and thereafter as needed.

Results will be reported to QA for further review and recommendations.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 and interview, it was determined the facility failed to ensure access to fire alarm devices and maintain fire alarm components in operable condition, affecting the entire facility.

Findings include:

1. Document review on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed the fire alarm inspection reports dated September 10, 2019 and March 11, 2019 indicated "the junction box/next to FACP - no battery."

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed there were deficient conditions of the fire alarm system.


2. Observation on January 28, 2020, at 12:51 p.m., revealed items stored in the corridor means of egress (geri-chair, lift, table), blocking access to the manual pull station outside room 26, 1st floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the obstruction to the fire alarm device.


3. Observation on January 28, 2020, at 1:30 p.m, revealed there were boxes and storage housed in the corridor, blocking access to the manual pull station, basement.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the obstruction to the fire alarm device.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws

Junction box is directly tied into the building power supply and it's not manually tested, documentation will be obtained supporting proper operation of the junction box/next to FACP. Items blocking corridor accessing the manual pull station outside room 26, 1st floor were removed

All other like areas were inspected, and no issues found

Staff will be educated by maintenance Director/ Designee on making sure hallways to the manual pull stations are free from any clutter giving a clear path to the exit doors in case of an emergency

Maintenance director will do 2x a week for 4 weeks, 2x a month for 2 months and thereafter as needed.

Results of the audit will be reported to QA for further review and recommendations

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 required inspections of the automatic sprinkler system and ensure components remain in operable condition, affecting the entire facility.

Findings include:

1. Document review on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed
the following automatic sprinkler system deficiencies:

a. the quarterly sprinkler report for the non vane-type/pressure switch-type automatic sprinkler system lacked a quarterly sprinkler inspection for the first quarter of 2019 (January through March);

b. the quarterly sprinkler report dated December 4, 2019 indicated "the tamper on the highest control valve did not operate properly at the time of inspection and needs to be adjusted as soon as possible;"

c. the quarterly sprinkler report dated June 5, 2019 indicated "multiple fusible link sprinklers in the kitchen and basement were found corroded at the time of inspection and need to be replaced as soon as possible;"

d. the covers were removed from the fire department connections at the ambulance entrance.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed there were deficient components of the automatic sprinkler system.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws

Proper documentation for the quarterly inspection for the non vane- type/ pressure switch- type automatic sprinkler system done on 3/11/2019 was obtained

Tamper switch on the highest control valve was adjusted on 01/29/2020
Fusible link sprinklers in the kitchen and basement were inspected on December 4th 2019 and no deficiencies noted
Covers were put back on the fire department connections and at the ambulance entrance.
Corroded sprinkler heads were replaced and an updated report showing no deficiencies was obtained. Documentations showing corroded sprinkler heads were replaced will be obtained.

Maintenance director/designee will do audits 1x per month for 2 months and as needed thereafter to ensure proper maintenance and testing of the
sprinklers.

Results of the audit will be reported to QA for further review and recommendations.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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, document review and interview, it was determined the facility failed to secure portable fire extinguishers, affecting one of three levels.

Findings include:

1. Document review and observation on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed the fire extinguisher annual inspection report dated September 19, 2020 indicated "fire extinguisher #28 needs mounting as soon as possible." The fire extinguisher was sitting on a bench inside the maintenance/housekeeping office at the time of inspection.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the fire extinguisher had not been secured.




 Plan of Correction - To be completed: 03/20/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Fire extinguisher #28 has been secured and no longer on the work bench

All other fire extinguishers have been secure

Maintenance Director/ Designee will be educated by administrator/ designee on making sure that all fire extinguishers have been secured

Maintenance Director/ designee will do audits 1x per week for 4 weeks, then 2 times per month for 2 months and as needed thereafter to ensure all fire extinguishers have been secured.

Results of the audit will be reported to QA for further review and recommendations

NFPA 101 STANDARD Corridor - 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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with smoke tight resistance and positive self-latching into their frames, affecting two of four smoke compartments.

Findings Include:

1. Observation on January 28, 2020, between 1:01 p.m. and 1:02 p.m., revealed the following corridor doors and bathroom doors were interlocked, prohibiting the corridor doors from latching into their frames, 2nd floor:

a. at 1:01 p.m., resident room 232;
b. at 1:02 p.m., resident room 227.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the corridor doors were obstructed from closing.


2. Observation made on January 28, 2020, between 1:15 p.m. and 1:48 p.m., revealed the following resident room corridor doors were deficient:

a. at 1:15 p.m., resident room 10 door had swelled, allowing resistance to closing, 1st floor;
b. at 1:48 p.m, resident room 211 would not latch into its frame when tested, 2nd floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the corridors door required adjustment.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Resident room 232, 227 doors were cleared from interlocking and latched into their frames

Room 10, 211 doors have been repaired so that it closes and latches properly
Staff will be educated by the

Maintenance Director will do audit 2 x a week for four weeks for 4 weeks, then 2 times a month for 2 months and as needed thereafter to ensure doors latch to their frames.

Results will be reported to QA for review and recommendations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation, document review and interview, it was determined the facility failed to provide required smoke barrier partitions and maintain the minimum travel distances for each smoke compartment, affecting two of three levels within the facility.

Findings include:

1. Document review and Observation on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed the facility lacked a required smoke barrier partition on the 2nd floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance, on January 28, 2020, at 3:30 p.m., confirmed the lack of a smoke barrier separation on the 2nd floor.


2. Document review and observation on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed smoke compartments #2 and #3, had travel distances that exceeded the allowable 200 feet, 1st floor.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the travel distances were excessive.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Silver lake would like an FSES completed by the Division of Life Safety for the smoke barrier partition on the 2nd floor
Silver Lake would like an FSES completed by the Division of Life Safety for smoke compartments #2 and #3 (located on the first floor), which has travel distances that exceed the allowable 200 feet

NFPA 101 STANDARD HVAC: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.
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, Ventilation, and Air Conditioning (HVAC) equipment in operable condition, affecting the entire facility.

Findings include:

1. Observation on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed the fire damper inspection/testing report dated March 9, 2018 indicated fire dampers which did not function, were blocked or inaccessible. Verification of repairs was not available at the time of inspection.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed there were deficient fire dampers.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws

Fire dampers will be replaced, dampers will also be accessible and will be not be blocked

An audit was conducted, and no other issues were noted

Maintenance director/ Designee will be educated on making sure fire nonfunctional fire dampers are replaced

Maintenance Director/Designee will do a quarterly and as needed audit to ensure nonfunctional fire dampers are replaced.

Results will be reported to QA for review and recommendations

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain use of authorized containers at designated smoking areas, affecting one of three levels.

Findings include:

1. Observation on January 28, 2020, at 12:10 p.m., revealed cigarette butts in the flower beds at the exterior designated smoking area near the recreation room.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed cigarette butts were not disposed of properly.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Cigarette butts in the flower beds at the exterior designated smoking area near the recreation room were collect
An audit was conducted, and no other issues were noted

An audit will be conducted by maintenance director/ designee 5x per week for 4 weeks and 2 times per month for two months and as needed thereafter to ensure no cigarettes butts on the floor bed.

Results reported to QA for further review and recommendations.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to record inspection/testing of required components of fire rated door assemblies, affecting the entire facility.

Findings include:

1. Document review on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed the annual fire door inspection report dated December 9, 2019 indicated a pass or fail only of the fire doors. A detailed checklist on the components inspected was not available at the time of inspection.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the fire door testing/inspection report was incomplete.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Detailed checklist on the components inspected on the doors was obtained
An audit was conducted, and no other issues were noted

Audit will be conducted after annual fire door inspection to make sure a detailed checklist on the components inspected are in place.

Results reported to QA for further review and recommendation

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on document review and interview, it was determined the facility failed to maintain required components of the alternate power source for the Essential Electrical System, affecting the entire facility.

Findings Include:

1. Observation on January 28, 2020, between 9:00 a.m. and 3:30 p.m., revealed both diesel-powered emergency generators lacked a labeled remote manual stop station.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed emergency generator component was not installed.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Remote manual stop stations on the generator will be installed
Audit conducted and no other issues noted

A monthly audit will be conducted for two months and as needed thereafter to ensure stop stations are in place.

Results reported to AQ for further review and recommendations

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

Based on document review and interview, it was determined the facility failed to secure the alternate power source for the Essential Electrical System, affecting the entire facility.

Findings Include:

1. Observation on January 28, 2020, at 12:25 p.m., revealed both diesel-powered emergency generator housing's were not locked against unauthorized access.

Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the emergency generators were not secured.




 Plan of Correction - To be completed: 03/10/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

New lock was installed to ensure the generator housings stay locked
Audit was conducted and no other issues noted

Monthly audits will be conducted for two months and as needed thereafter to ensure the generator housings are locked against unauthorized access.

Results reported to AQ for further review and recommendations


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