Pennsylvania Department of Health
AVENTURA AT PROSPECT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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AVENTURA AT PROSPECT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 6, 2025, it was determined that Aventura at Prospect was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.

Findings include:

Document review on May 6, 2025, at 11:30 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m. confirmed the documentation was not available.

Plan of Correction - To be completed: 06/13/2025

1. Facility has a current emergency preparedness plan that will be updated at least annually
2. NHA/Designee will audit emergency preparedness plan for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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

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

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

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

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

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

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

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

Findings Include:

Document review on May 6, 2025, at 11:30 a.m., revealed facility failed to develop Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m. confirmed the documentation was not available.

Plan of Correction - To be completed: 06/13/2025

1. Facility has an emergency preparedness policy and procedure for medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
2. NHA/Designee will audit that EP policy and procedure for medical documentation is in place for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training 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.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on documentation review and interview, it was determined the facility failed to develop
an emergency preparedness training program that is based on the facility's emergency preparedness plan. The training and testing program must be reviewed and updated at least annually, affecting the entire facility.

Findings include:

Document review on May 6, 2025, at 11:30 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m. confirmed the documentation was not available.

Plan of Correction - To be completed: 06/13/2025

1. Facility has a current emergency preparedness training and testing program that is based on the facility's emergency preparedness plan that will updated annually.
2. NHA/Designee will audit emergency preparedness training and testing program for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

403.748(d)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program:

§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Observations:
Name: - Component: -- - Tag: 0037

Based on documentation review and interview, it was determined the facility failed to maintain a training program that is based on the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

Document review on May 6, 2025, at 11:30 a.m., revealed the facility failed to perform training to the emergency preparedness plan that included the following:

a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
b. Provide emergency preparedness training at least annually.
c. Maintain documentation of the training.
d. Demonstrate staff knowledge of emergency procedures.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m. confirmed the documentation was not available.

Plan of Correction - To be completed: 06/13/2025

1. Facility has an emergency preparedness training program that is based on the facility's emergency preparedness plan that will updated annually.
2. NHA/Designee will audit emergency preparedness training program for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039

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

Findings include:

Document review on May 6, 2025, at 11:30 a.m., revealed the facility failed to conduct an annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution within the previous 12 months.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m. confirmed the documentation was not available.

Plan of Correction - To be completed: 06/13/2025

1. Facility has documentation of a situation that utilized the facility emergency preparedness plan on /31/2025 and will complete an emergency exercise annually.
2. NHA/Designee will audit documentation monthly for three months. Results of the audit will be taken through the facility's monthly QAPI meeting.

Initial comments:Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID# 162502
Component 01
North Wing, South Wing, Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2025, it was determined that Aventura At Prospect was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating for the building construction, affecting the entire facility.

Findings include:

Document review on May 6, 2025, at 11:30 a.m., revealed the building was classified as a two story, Type V (000), unprotected wood frame construction, which is fully sprinklered. This type of construction is not permitted to exceed one-story in height.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the story height exceeded the maximum requirement for an unprotected wood frame construction.

Plan of Correction - To be completed: 06/13/2025

1. Time limited waiver continuation was requested. FSES on file that reflects current conditions within the facility.
2. A review of the plans to bring the building into compliance and architectural plan for the facility will be presented to the QAPI Committee for review for 1 month.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0223

Based on observation, document review, and interview, it was determined the facility failed to ensure magnetic hold-open devices function properly, affecting one of three levels.

Findings include:

Observation and document review on May 6, 2025, at 12:00 p.m., revealed, on the second floor, magnetically held doors failed to release as required upon activation of the fire alarm.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the fire alarm deficiency.

Plan of Correction - To be completed: 06/13/2025

1. Doors on the second floor that are magnetically held open now release as required upon activation of the fire alarm
2. NHA/Designee will audit second floor magnetic doors for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair tower enclosures, affecting one of four stair towers.

Findings include:

Observation on March 6, 2025, at 12:45 p.m., revealed 2 North fire exit stair had an unsealed penetration around a drywall patch.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the unsealed penetration of the stair tower enclosure.

Plan of Correction - To be completed: 06/13/2025

1. 2 North stair tower is now patched, repaired, and sealed with fire-stop product W L 3081.
2. NHA/Designee will audit stair tower fire resistance for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0324

Based on interview and documentation review, it was determined the facility failed to ensure the kitchen fire suppression system was inspected, affecting one of two semi-annual inspections.
Findings include:
Document on May 6, 2025 between 11:00 a.m. and 1:50 p.m., revealed the facility could not produce documentation that a semi-annual inspection was performed on the kitchen fire suppression system for the previous 12 months.
Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed a semi-annual inspection was not performed.

Plan of Correction - To be completed: 06/13/2025

1. Facility now has documentation of kitchen suppression system inspections
2. NHA designee will audit kitchen suppression system inspection documentation for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to ensure fire alarm systems such as smoke detection devices were maintained and tested as required, affecting the entire component.
Findings include:
Document review on May 6, 2025, between 11:00 a.m. and 1:50 p.m., revealed the following:
a. Facility was unable to provide documentation indicating every two years the smoke detectors had a sensitivity test performed.
b. facility was unable to provide documentation that semi-annual fire alarm inspections had been performed for the previous calendar year
Exit interview with the Administrator and Maintenance Director, on May 6, 2025 at 1:50 p.m., confirmed the documentation was unavailable.

Plan of Correction - To be completed: 06/13/2025

1. a. Facility has documentation that sensitivity testing was performed
b. Facility has documentation of the semi-annual fire alarm inspections were performed.

2. NHA designee will audit sensitivity testing documentation for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0347

Based upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of three levels.

Findings include:

Observation on May 6, 2025, at 11:40 a.m., revealed, in 2 South fire exit stair, a smoke detector was missing from its housing.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the missing smoke detector.

Plan of Correction - To be completed: 06/13/2025

1. Smoke detector in 2 South fire exit stairs is now in place
2. NHA/Designee with audit smoke detector for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0353

Based on document review, observation, and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.
Findings include:
1. Document review on May 6, 2025, between 11:00 a.m. and 1:50 p.m. revealed the following:
a. the facility failed to provide a semi annual sprinkler inspection report for the previous 6 months.
b. the facility failed to provide an internal valve, pipe and obstruction inspection for the previous 5 years.
Exit interview with the Administrator and the Director of Maintenance, on May 6, 2025, at 1:50 p.m., confirmed the lack of documentation.

2. Observation on March 6, 2025, at 11:15 a.m., revealed a missing Fire Department Connection (FDC) cap, exterior building by maintenance.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the missing FDC cap.

Plan of Correction - To be completed: 06/13/2025

1. A. Facility has documentation of semiannual sprinkler inspection for the previous 6 months
B. Facility has documentation of internal valve, pipe and obstruction inspection for the previous 5 years
C. FDC has been replaced
2. NHA/Designee will audit documentation for sprinkler inspection and internal valve, pipe, and obstruction inspection for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0371

Based on document review and interview, it was determined the facility failed to ensure smoke compartments were maintained within minimum square footage requirements, affecting five of five smoke compartments.

Findings include:

Document review on May 6, 2025, at 11:30 a.m., revealed smoke compartments on resident sleeping room floors, exceeded 22,500 square feet.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the smoke compartments were greater than 22,500 square feet.

Plan of Correction - To be completed: 06/13/2025

1. FSES submitted to DOH plan review showing smoke compartments do not exceed 22,500 square feet would like deficiency eliminated. FSES submitted to sharepoint DOH site. Square footage of smoke compartments documented on the FSES.
2. NHA/Designee will audit smoke compartments and matching floor plans for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of three levels.

Findings include:

Observation on May 6, 2025, at 12:30 p.m., revealed, on the second floor above smoke doors by room 219, an unsealed penetration around data wires.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the penetration.

Plan of Correction - To be completed: 06/13/2025

1. Penetration has been sealed and caulked around data wires on the second floor with firestop product number W L 3081.
2. NHA/Designee will audit previously penetrated wall for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained, affecting one of three levels.

Findings include:

on May 6, 2025, at 1:20 p.m., revealed, in the basement, the smoke door by the folding room was propped open with a board.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the propped door.

Plan of Correction - To be completed: 06/13/2025

1. Door obstruction was removed. Staff educated to not prop door and the importance of not propping.
2. NHA/Designee will audit smoke doors daily for 7 days and weekly for 2 months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Smoking Regulations:

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0741

Based on document review and interview, it was determined the facility failed to provide documentation of a smoking/non- smoking policy and maintain designated smoking areas.
Findings include:
1. Document review on May 6, 2025, between 11:00 a.m. and 1:50 p.m., revealed the facility failed to provide documentation of a policy for smoking / non-smoking.
Exit interview with the Administrator and Maintenance Director on May 6, 2025 at 1:50 p.m., confirmed the lack of documentation.

2. Observation on May 6, 2025, at 11:30 a.m., revealed, the designated smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area and not in the provided ash receptacles.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the improperly discarded cigarette butts.

3. Observation on May 6, 2025, at 11:31 a.m., revealed the designated smoking area ash receptacles had combustible debris mixed in with discarded cigarette butts.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the deficiency.

Plan of Correction - To be completed: 06/13/2025

1. Facility has a smoking policy and it was updated to include designated smoking areas.
Staff educated to use the ash receptacle for cigarettes and trash cans for trash and to redirect residents to use ash receptacle and trash cans.
B. Smoking area is cleaned after every resident smoke break.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting three of five smoke compartments.

Findings include:

Observation on May 6, 2025, revealed electrical system deficiencies in the following locations:

a. 12:05 p.m., Central Supply crawlspace- junction box missing cover.
b. 12:06 p.m., Central Supply crawlspace- electrical panel missing its cover.
c. 12:20 p.m., in the basement sprinkler room, junction box missing its protective cover.
d. 12:22 p.m., in the basement sprinkler room- damaged duplex receptacle, exterior wall.

~Refer to 2011 edition of NFPA 70-314.28.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the exposed wiring.

Plan of Correction - To be completed: 06/13/2025

1. A. Central supply crawl space junction box cover installed
B. Central supply crawl space electrical panel has been installed
C. Basement sprinkler room junction box protective cover has been installed
D. Basement sprinkler room damaged duplex receptacle has been disabled and covered with a blank plate
2. NHA/Designee will audit coverings and junction box for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0918

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

Document review on May 6, 2025, between 11:00 a.m. and 1:50 p.m., revealed the facility could not produce documentation of the following required testing and inspections:

a.Monthly 30-min load test
b. Monthly operation of transfer switches
c.(Annual) 90 min Load Bank if cannot meet 30% of nameplate
d. Diesel Generator's PM report with no evidence of wet-stacking and meets manufacturer ' s specs
e. 3 year, 4-hour Load Test
f.Annual Fuel Quality Test, last documented test is dated 2023

Exit interview with the Administrator and Director Maintenance on May 6, 2025, at 1:50 p.m., confirmed the facility lacked documentation for the required testing and inspections.

Plan of Correction - To be completed: 06/13/2025

1. Facility has emergency generator documentation of the following
a. Monthly 30- minute load test
b. Monthly operation of transfers
c. 90 min load bank
d. Diesel generator PM report with wet stacking
e. 3-year, 4-hour load test
f. Annual fuel quality test
2. NHA/Designee will audit generator documentation for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: NORTH, SOUTH, MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to ensure that the improper and unauthorized use of extension cords and surge protectors are prohibited on two of three levels.

Findings include:

Observation on May 6, 2025, revealed the improper use of electrical devices in the following locations:

a. 11:40 a.m., the activities on the first floor, microwave and fridge plugged into power strip.
b. 11:55 a.m., the kitchen in the basement, microwave and fridge plugged into power strip.

Exit interview with the Administrator and Maintenance Director on May 6, 2025, at 1:50 p.m., confirmed the unauthorized use of electrical devices.

Plan of Correction - To be completed: 06/13/2025

1. Power cords and extension cords have been removed from the activity's office and the kitchen office.
2. NHA/Designee will audit that power strips are not in use for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly QAPI meeting.

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