Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT PALMYRA
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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KADIMA REHABILITATION & NURSING AT PALMYRA - 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 August 20, 2024, at Kadima Rehabilitation & Nursing at Palmyra, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #161102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 20, 2024, it was determined that Kadima Rehabilitation & Nursing at Palmyra 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 483.90(a).

This is a one-story, Type V (111), protected wood frame structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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.

Plan of Correction - To be completed: 10/18/2024

I: The facility is unable to retroactively correct. The portable life safety drawings were updated to include the room capacities, hazardous areas, travel distances, and labeled use of spaces.

2: The maintenance director was reeducated on the need to document annual testing and inspection of installed carbon monoxide alarms, per manufacturers' specifications.

3: A facility-wide audit of the carbon monoxide alarms to ensure it can be heard by all staff on duty.

4: The maintenance director was educated on the need conduct and document evacuations and alarm protocols.

5: The facility also installed a carbon monoxide detector in close proximity but more than 15 feet from any fossil fuel-burning device. The NHA or designee will conduct monthly x 2 month to ensure alarm protocols are followed. Results will be submitted to QAPI committee for review.

NFPA 101 STANDARD Means of Egress - General:

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 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain corridors to be unobstructed, and failed to maintain the maximum force required to operate exit discharge doors, affecting two of two floors within the component.

Findings include:

1. Observation on August 20, 2024, at 10:45 AM, revealed the headroom, of the basement corridor, was approximately 6 feet 2 inches.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the headroom, in the basement corridor, was less than 6 feet 8 inches above the finished floor.

2. Observation and interview on August 20, 2024, between 10:15 AM and 10:55 AM, revealed exit discharge doors required a force of more than 30 pounds to set the doors in motion, at the following locations:

a. 10:15 AM, basement;
b. 10:55 AM, 1st floor, by Resident Room 119.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the doors did not begin to swing with an applied force of 30 pounds.

Plan of Correction - To be completed: 10/18/2024

1.The facility is requesting FSES for the headroom OF the basement

2: The cited observations cannot be retroactively corrected, exit doors have been repaired and will no longer require more than 30 pounds to set the doors in motion, maintenance director or designee will audit discharged doors to ensure doors don't need more than pounds 30 to swing.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

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

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide not less than two exits, remote from one another, for each floor, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on August 20, 2024, at 10:40 AM, revealed a single exit from the basement.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the basement did not have at least two exits, remote from each other.

Plan of Correction - To be completed: 10/18/2024

1: The facility cannot retroactively correct.

2: The facility is requesting a FSES for the second exit in the basement.

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 - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility failed to maintain battery-powered emergency lighting sources, affecting the entire component.

Findings include:

1. Observation and interview on August 20, 2024, between 8:45 AM and 10:00 AM, it was revealed the facility failed to perform monthly and annual testing of battery powered emergency lighting sources.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed monthly and annual testing installed back-up emergency lighting testing were performed.

Plan of Correction - To be completed: 10/18/2024

1.The facility cannot retroactively correct.

2: A facility-wide annual testing of battery-powered emergency lighting sources was conducted on 1/18/2024.

3: The maintenance director was reeducated on the monthly and annual requirements of testing battery-powered emergency lightening. Which was conducted 8/21/2024, 9/2/2024 and 10/7/2024

4: The NHA or design will conduct monthly audit x 2 months and annual audit x 1 year to ensure testing occurs . Result will be submitted to QAPI for review.

NFPA 101 STANDARD Exit Signage:

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.

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 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide verification of monthly exit signs inspections, affecting two of two floors within the component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility lacked documentation verifying exit signs were visually inspected, for the last 12 months.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility failed to inspect exit signs, monthly.

Plan of Correction - To be completed: 10/18/2024

1: The facility cannot retroactively correct.

2: The monthly exit sign inspection was performed on 9/30/2024. The maintenance director was reeducated on the need to document and inspect exit signs monthly.

3: The DON or designee will complete an audit of the exit signs monthly x 3 months to ensure exit signs are inspected. The result will be submitted to QAPI committee for review and analysis for ongoing monitoring.

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins, and failed to maintain hazardous area doors, to be free from unauthorized material, affecting two of two floors within the component.

Findings include:

1. Observation on August 20, 2024, at 10:10 AM, revealed basement Laundry Chute Room door had gaps, 3/16-inch top and latch side, which exceeds the allowed gap margins.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the door exceeded the allowed gap margins.

2. Observation on August 20, 2024, between 10:20 AM and 10:23 AM, revealed hazardous area doors had holes filled with unauthorized material around the lockset, at the following locations:

a. 10:20 AM, basement, Inventory Storage Room;
b. 10:23 AM, basement, Kitchen Day Storage.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the rated doors had holes, which were filled with unauthorized material.

Plan of Correction - To be completed: 10/18/2024

: The facility cannot retroactively correct.

2: The facility has repaired and closed area door gap margins using metal plates. The holes were closed, and all hazardous and unauthorized materials were removed.

3: A facility-wide audit will be conducted to ensure that there are no gaps and unauthorized materials on the door.
4: The NHA or designee will conduct a monthly audit of random rated doors monthly to make sure that area doors are in good repair and the repairs were done using approved accessories. QAPI committee will review this project and all upcoming facility project to ensure approved accessories are used.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to provide owner's checks, semi-annual hood cleanings and semi-annual testing of the fixed chemical fire suppression system, in one of two floors within the component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility could not provide documentation, verifying the Kitchen's fixed chemical fire suppression system had been tested/maintained, semi-annually. Documentation verified the last inspection was completed December 8, 2023.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility could not provide one full year of semi-annual suppression system inspection documentation.

2. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility could not provide documentation, verifying the Kitchen exhaust ductwork had been cleaned, on a semi-annual basis. Documentation verified last cycle was completed on July 23, 2024.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility could not provide one full year of semi-annual kitchen ductwork cleaning documentation.

3. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility failed to document owner's quick checks of the fixed chemical fire suppression system, in the Kitchen.

Interview at the time of the exit conference with the Administrator and Director of Maintenance and on August 20, 2024, at 1:15 PM, confirmed the facility failed to conduct the owner's quick checks on the Kitchen's fixed chemical fire suppression system.

Plan of Correction - To be completed: 10/18/2024

1.The facility cannot retroactively correct.

2: The maintenance director will be re-educated on the need to schedule maintain and document in the LIFE SAFETY BOOK the kitchen-fixed chemical fire suppression system semiannually.
3: The kitchen hood extinguishing system has been inspected and maintained on 10/2/2024

4: The NHA or designee will conduct an audit quarterly to ensure that the kitchen fixed chemical fire suppression system has been maintained and fixed and the ductwork cleaned on 09/26/2024. the result of which will be submitted to QAPI committee for review and analysis of need for ongoing monitoring.

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 - Component: 01 - Tag: 0345

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

Findings include:

1. Review of documentation on August 20, 2024, between 9:05 AM and 9:10 AM, revealed the facility lacked documentation, verifying the following inspection was performed:

a. 9:05 AM, fire alarm, semi-annual visual;
b. 9:07 AM, fire alarm, two-year sensitivity;
c. 9:09 AM, fire alarm, supervisory, semi-annual;
b. 9:10 AM, fire alarm, waterflow, semi-annual.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM confirmed the fire alarm inspections were not performed.

Plan of Correction - To be completed: 10/18/2024

1:S.A Comunale conducted a fire alarm and detector sensitivity testing on the facility on 09/03/2024
2: A facility wide audit of the fire alarm system was conducted to ensure they were in good condition.

3: The maintenance director was re-educated on maintenance and documentation of audit of the alarm system.

4: NHA or designee will complete an audit x 2 times a year of the fire alarm system to ensure appropriate maintenance and documentation. Result will be reviewed at QAPI

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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

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

Based on document review, observation and interview, it was determined the facility failed to provide quarterly maintenance documentation, repair reports for noted deficiencies and maintain sprinkler heads, to be free of obstructions, affecting two of two smoke zones within the component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility lacked documentation for the 3rd quarter wet system inspection report.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility could not provide documentation for the third quarter wet sprinkler systems.

2. Review of documentation and interview on August 20, 2024, between 9:15 AM and 9:20 AM, revealed the following deficiencies, for the sprinkler system, were found by Johnson Controls:

a. 9:15 AM, deficient anti-freeze solution, 11/17/2023 and 2/15/2024;
b. 9:20 AM, no hydraulic nameplate present.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility failed to replace the anti-freeze solution.

3. Observation on August 20, 2024, at 10:30 AM, revealed storage within 18 inches of the sprinkler head in the Kitchen walk-in freezer.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed there was storage was within 18 inches of the sprinkler heads.

4. Observation on August 20, 2024, between 10:42 AM and 10:52 AM, revealed sprinkler heads had a significant load, at the following locations:

a. 10:42 AM, 1st floor, Ice Machine Room;
b. 10:44 AM, 1st floor, Dining Room 4;
c. 10:52 AM, 1st floor, Nurses' Station 1.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the sprinkler heads were loaded.

Plan of Correction - To be completed: 10/18/2024

1.The maintenance director was re-educated on the requirements of 0353.

2: A facility-wide audit was conducted to ensure no items are stored with 18-inch or sprinkler heads.

3: The NHA or designee will conduct an audit weekly x 4 weeks and then monthly x 2 months to ensure nothing is stored 18 inches or sprinkler heads. The result will be submitted to QAPI committee for review and analysis and ongoing monitoring.

NFPA 101 STANDARD Portable Fire Extinguishers:

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

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

Based on document review and interview, it was determined the facility failed to provide documentation of annual inspection and certificate for the fire extinguisher technician, affecting the entire component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility lacked documentation of annual inspection report, detailing number of extinguishers inspected, types of extinguishers inspected, any deficiencies and on an official company document.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility lacked fire extinguisher documentation.

2. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility lacked documentation of the annual inspection being completed by a Certified Fire Extinguisher Inspector.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility could not provide a certification for Fire Extinguisher Inspector.

Plan of Correction - To be completed: 10/18/2024

1: The facility is unable to retroactively correct this practice.

2: The maintenance director was re-educated on  annual fire extinguisher inspection report and the requirement of 0355.
3: The facility conducted a fire extinguisher inspection on 10/3/2024, the annual fire extinguisher, report will be filed in the Life Safety book
4: The NHA or designee will conduct a monthly audit to ensure that the fire extinguishers are in order, results will be submitted to QAPI for review

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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 - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide at least two smoke compartments, affecting one of two floors within the component.

Findings include:

1. Observation on August 20, 2024, at 11:30 AM, revealed the facility lacked a smoke barrier on the Resident Sleeping Floor.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the lack of a smoke barrier wall.

Plan of Correction - To be completed: 10/18/2024

Cited observations cannot be retroactively corrected. The maintenance director will audit residents' sleeping floors to ensure smoke barriers are in place.

2: Smoke barriers have been provided on all sleeping floors.

3. A facility-wide audit was conducted to ensure that smoke barriers are in place.

NFPA 101 STANDARD Utilities - Gas and Electric:

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

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

Based on observation and interview, it was determined the facility failed to maintain access to emergency gas shut off valves, affecting one of one gas main rooms within the component.

Findings include:

1. Observation on August 20, 2024, at 10:18 AM, revealed excessive storage within the Gas Line Room, preventing access to emergency shut off valves.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed access, to emergency shut off valves, were obstructed.

Plan of Correction - To be completed: 10/18/2024

1:A facility-wide audit of the gas line room was conducted to ensure they were not obstructed, the objects were removed to ease access to the emergency shut off valves.
2. Facility staff were reeducated on ensuring gas line room is not obstructed. The NHA or designee will complete an audit of the gas line room weekly x 4 weeks and then quarterly to ensure they are unobstructed. The results will be submitted to the QAPI committee for review and ongoing monitoring.

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 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility lacked documentation, verifying the 4-year fire damper maintenance and exercise was performed, in two of two floors within the component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility failed to provide documentation of the fire damper inspection.

Plan of Correction - To be completed: 10/18/2024

1: The facility cannot retroactively correct.

2: The fire damper inspection will take place on 10/14/2024 The maintenance director was reeducated on verifying and documentation of the 4-year fire damper maintenance ad exercise.

3: The NHA or designee will complete an annual audit to verify the documentation of the 4-year fire damper exercise and maintenance in the LIFE SAFETY BOOK.The result will be
submitted to QAPI committee for review and analysis of the need for ongoing monitoring.

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 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct and perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility did not perform fire drills, during the following:

a. 1st quarter 2024, 1st shift;
b. 2nd quarter 2024, 1st shift, 2nd shift and 3rd shift.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility could not provide documentation, verifying the fire drills were performed.

Plan of Correction - To be completed: 10/18/2024

1: The facility is unable to retroactively correct this practice.

2: The maintenance director was re-educated on conducting fire drills.

3.The facility has designed a fire drill matrix and all the dates for fire drills has been assigned.
3: The NHA or designee will conduct a quarterly audit on the life safety book to ensure fire drills are conducted one fire drill per shift per quarter. Results will be submitted to QAPI committee for review.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to provide documentation of the annual fire door inspection, affecting the entire component.

Findings include:

1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the facility lacked documentation of the annual fire-rated door inspection.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the facility could not provide documentation of the annual fire door inspection.

Plan of Correction - To be completed: 10/18/2024

1: The facility is unable to retroactively correct this practice. The fire alarm inspection has been completed on 09/03/2024

2:The maintenance director was reeducated on conducting and documenting of annual fire door inspections.

3: The NHA or designee will conduct an audit every 3 months to make sure fire doors are inspected and documented in the Life Safety book, results will be submitted to QAPI committee for review.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles, to be Ground Fault Interruption (GFI) protected, within six feet of a water source, in one of two smoke compartments within the component.

Findings include:

1. Observation on August 20, 2024, between 10:40 AM and 10:49 AM, revealed outlets were not GFI protected and within six feet of a water source, at the following locations:

a. 10:40 AM, 1st floor, Ice Machine Room, 2 outlets;
b. 10:49 AM, 1st floor, Soiled-utility Room, 1 outlet.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the outlets were not GFI protected.

Plan of Correction - To be completed: 10/18/2024

1: The facility is unable to retroactively correct this practice.

2: The facility has maintained the power receptacles by making it GFI protected within six feet of the water source on 10/2/2024.

3: The NHA or designee will complete an audit of the power receptacle weekly x 4 weeks and then monthly x 2 months to ensure outlets are protected. The results will be submitted to the QAPI

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to conduct electrical outlet testing in patient care areas, in two of two smoke zones within the component.
Findings include:
1. Review of documentation on August 20, 2024, between 8:45 AM and 10:00 AM, revealed the required annual inspection of receptacles, in patient care areas, was not performed.
Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the annual inspection and test was not performed.

Plan of Correction - To be completed: 10/18/2024

1: The facility is unable to retroactively correct this practice.

2: The maintenance director was re-educated on the annual inspection of receptacles in patient care areas.

3: The annual patient care electrical receptacle inspection was conducted on 10/8/2024

3: The NHA or designee will conduct an audit of the patient care receptacle. The audit of the Life Safety Book will be conducted semi annually to ensure receptacles are inspected. results will be submitted to QAPI for review.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide required maintenance and testing documentation for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on August 20, 2024, between 9:47 AM and 9:51 AM, revealed the facility lacked documentation, for the following:

a. 9:47 AM, one full year, weekly visual inspection;
b. 9:48 AM, one full year, monthly building load run, 30-min load w/transfer switch;
c. 9:49 AM, annual load bank;
d. 9:50 AM, 3-year, 4-hour building load run;
e. 9:51 AM, annual fuel quality test report.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the emergency generator maintenance was not performed.

Plan of Correction - To be completed: 10/18/2024

1: The facility maintained emergency generator on 1/18/2024 and have subsequently gotten the documentation from Penn Power.

2: The maintenance director was re-educated on the maintenance, testing and documentation of the emergency generator.

3: The NHA or designee will conduct a monthly audit of the testing x 2 a month x 12 months to ensure the maintenance and testing of the energy generator.

NFPA 101 STANDARD Electrical Equipment - Other:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical junction boxes to be covered, on one of two floors within the component.

Findings include:

1. Observation on August 20, 2024, at 10:47 AM, revealed an electrical junction box lacked a cover plate, in the Main Hall, above the ceiling, by Resident Room 105.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on August 20, 2024, at 1:15 PM, confirmed the missing box cover.

Plan of Correction - To be completed: 10/18/2024

1.The missing electrical junction box cover above the ceiling has been replaced.

2: The maintenance director was reeducated on the maintenance of electrical boxes.

3: The NHA or designee will conduct a monthly audit x 2 months to ensure that the electric junction box is maintained. documented, results will be submitted to QAPI committee for review.

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