Pennsylvania Department of Health
QUADRANGLE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 41 surveys for this facility. Please select a date to view the survey results.

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QUADRANGLE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on a Revisit to an Emergency Preparedness Survey completed on June 26, 2024, it was determined that The Quadrangle had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Based on document review and interview, it was determined the facility failed to conduct testing exercises of the Emergency Preparedness (EP) plan, affecting the entire facility.

Findings include:

1. Documentation reviewed on June 26, 2024, revealed the facility failed to conduct an annual full-scale community-based or facility-based exercise of the emergency plan, in addition to a second full-scale community-based or individual, facility-based exercise or a tabletop exercise that includes a group discussion led by a facilitator.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed Emergency Preparedness training exercise were not completed.

******************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Item 1. Not Completed. The facility failed to conduct an annual full-scale community-based or facility-based exercise of the emergency plan, in addition to a second full-scale community-based or individual, facility-based exercise or a tabletop exercise that includes a group discussion led by a facilitator.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed Emergency Preparedness training exercise were not completed.

Plan of Correction - To be completed: 09/24/2024

B. With respect to how the facility will identify residents/situations for the identified concerns:

The Engineering Director will conduct an Emergency Plan exercise with the team.

C. With respect to what systemic measures have been put into place to address the stated concern:

Engineering Director will be provided training on drill and emergency plan exercises, per regulation.

D. With respect to how the plan of correction will be monitored:

The Administrator and QAPI Committee will ensuring implementation and compliance of emergency plan exercises and drills, per regulation.

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

Facility ID #170702
Component 01
Health Care Oak Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on June 26, 2024, it was determined that The Quadrangle was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common fire wall separations from non-healthcare buildings, affecting 1 of two levels.

Findings Include:

1. Observation made on June 26, 2024, at 3:27 p.m., revealed one leaf of the double doors at the fire separation leading to the tunnel could not be tested manually to confirm positive latching in its frame, 1st floor.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed the fire door required adjustment.

***********************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Item 1. Not Completed. One leaf of the double doors at the fire separation leading to the tunnel could not be tested manually to confirm positive latching in its frame, 1st floor.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed the fire door required adjustment.

Plan of Correction - To be completed: 09/24/2024

A. With respect to the specific resident/situation cited:
The Engineering Director reviewed and corrected the latching of the identified door.

B. With respect to how the facility will identify residents/situations for the identified concerns:

The Engineering Director has audited all doors that require positive latching for proper closure and function. Parts have been delivered and will be installed thereafter.

C. With respect to what systemic measures have been put into place to address the stated concern:

The engineering department will audit all doors that require positive latching for proper closure twice weekly for 1 month, then weekly for another 60 days.

D. With respect to how the plan of correction will be monitored:

At the conclusion of the 3 months, the QAPI (Quality Assurance and Performance Improvement) committee will re-evaluate and initiate any necessary action or extend the review period if needed.

The Administrator is responsible for ensuring implementation and ongoing, compliance with the components of the Plan of Correction and addressing variances that may occur.

NFPA 101 STANDARD Fire Alarm System - Out of Service:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0346

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

Findings Include:

Documentation reviewed on June 26, 2024, revealed a fire watch policy, in the event the fire alarm system is out of service, was not available at the time of inspection.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed a written fire alarm policy was not provided.

******************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Not Completed. A fire watch policy, in the event the fire alarm system is out of service, was not available at the time of inspection.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed a written fire alarm policy was not provided.

Plan of Correction - To be completed: 09/24/2024

A. With respect to the specific resident/situation cited:
Sunrise has a fire watch policy in place, in the event of fire system impairment. Engineering department has ensured that the emergency binder has a current copy of the policy. A copy of the policy is available upon request.

B. With respect to how the facility will identify residents/situations for the identified concerns:

Engineering department has provided training to management staff of the fire watch policy. Management team informed that a copy of the policy is found in the emergency binder.

C. With respect to what systemic measures have been put into place to address the stated concern:

Engineering department will provide annual training for managers of the mentioned policy, and ensure that a current policy is in the emergency binder. HR will ensure and document annual training compliance.

D. With respect to how the plan of correction will be monitored:

Engineering department will provide training to QAPI IDT members of the Sunrise Fire Watch policy. Sunrise Fore Watch policy available upon request.

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 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain required inspections of portable fire extinguishers, affecting the entire facility.

Findings Include:

Observation made on Jun 26, 2024, at 2:48 p.m., revealed the following fire extinguisher deficiencies:

a. certification for personnel servicing fire extinguishers was not available;
b. the fire extinguisher inside the 2000 kw walk-in generator lacked a monthly visual inspection.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed fire extinguisher inspections documents were incomplete.

*****************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Item a. Not Completed. Certification for personnel servicing fire extinguishers was not available.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed fire extinguisher inspections documents were incomplete.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 09/24/2024

A. With respect to the specific resident/situation cited:
We will obtain the certificate for the person who has serviced the fire extinguishers. This information will be readily available.

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain smoke resistant corridor walls, in fully sprinklered compartments, affecting 1 of six smoke compartments.

Findings Include:

Observation made on June 26, 2024, at 3:14 p.m., revealed there were two transfer grills in the corridor wall of the SPA. This area seemed to be recently renovated. Fire dampers installed inside the grills does not prohibit the transfer of smoke into the corridor means of egress, 2nd floor.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed the corridor wall openings.

**********************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Not Completed. There were two transfer grills in the corridor wall of the SPA. This area seemed to be recently renovated. Fire dampers installed inside the grills does not prohibit the transfer of smoke into the corridor means of egress, on the second floor.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed the corridor wall openings.

Plan of Correction - To be completed: 09/07/2024

A. With respect to the specific resident/situation cited:
The grills have been moved to its permanent location, as renovation in that area is has been completed for that phase. The corridor walls are now smoke resistant.

NFPA 101 STANDARD Corridor - Doors:

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

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to resist the passage of smoke, in sprinklered locations, affecting 1 of six smoke compartments.

Findings Include:

1. Observation made on June 26, 2024, at 3:23 p.m., revealed the supply closet corridor door had a gap between the door and frame, across from room 120, 1st floor.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed the corridor door was not smoke tight in its frame.

******************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Item 1. Not Completed. The supply closet corridor door had a gap between the door and frame, across from room 120, on the first floor.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed the corridor door was not smoke tight in its frame.

Plan of Correction - To be completed: 09/24/2024

A. With respect to the specific resident/situation cited:
The maintenance director will ensure that the gap between the door and the frame in the identified area will be resolved.

B. With respect to how the facility will identify residents/situations for the identified concerns:

Engineer department will review all doors in accordance to regulations, to ensure meeting compliance. Any need for repairs will be addressed timely.

C. With respect to what systemic measures have been put into place to address the stated concern:

Engineering department will audit monthly X 3 months. Any need for repairs will be identified and rectified. Engineering Director will schedule annual third-party inspections of all appropriate doors for compliance.

D. With respect to how the plan of correction will be monitored:

At the conclusion of the 3 months, the QAPI (Quality Assurance and Performance Improvement) committee will re-evaluate and initiate any necessary action or extend the review period if needed.

The Administrator is responsible for ensuring implementation and ongoing, compliance with the components of the Plan of Correction and addressing variances that may occur.

NFPA 101 STANDARD HVAC:

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.

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain required inspections for heating and ventilating equipment, affecting the entire facility.

Findings Include:

Documentation reviewed on June 26, 2024, revealed a 4-year fire/smoke damper inspection/exercising report was not available at the time of inspection.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed testing of mechanical equipment was not available.

****************************

Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Not Completed. The 4-year fire/smoke damper inspection/exercising report dated July 8, 2024 was available for review. Three deficiencies were noted: 2 damper failures and 1 obstruction. Verification of repairs were not available at time of revisit.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed there were damper deficiencies.

Plan of Correction - To be completed: 09/24/2024

A. With respect to the specific resident/situation cited:
The identified deficient findings are being addressed. Parts have been ordered, and will be installed, once arrived.

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 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain fire doors in operable condition, affecting 7 of approximately 23 doors.

Findings Include:

Documentation reviewed on June 26, 2024, revealed the annual third party inspection report dated March 22, 2023, indicated 7 fire doors which failed inspection. Verification of repairs and an updated annual report were not available at the time of this survey.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed there were fire door deficiencies.

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Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Not Completed. The annual third party inspection report dated March 22, 2023, indicated 7 fire doors which failed inspection. Verification of repairs and an updated annual report were not available at the time of this survey

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed there were fire door deficiencies.

Plan of Correction - To be completed: 09/24/2024

Plan of Correction:
A. With respect to the specific resident/situation cited:
The engineering department has addressed the 7 fire doors which failed inspection, per report.

B. With respect to how the facility will identify residents/situations for the identified concerns:

Engineering Department has scheduled annual third-party inspection of the fire doors for 2024, and plans to address all deficient findings.

C. With respect to what systemic measures have been put into place to address the stated concern:

Engineering Department will maintain reports of all findings and all repairs made.

D. With respect to how the plan of correction will be monitored:

The repairs for the 2023 inspection, and the scheduled 2024 inspection and repair report will be reported to QAPI until completion.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

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

Findings Include:

1. Documentation reviewed on June 26, 2024, revealed the following testing/inspection reports were not available for both emergency generators:

a. weekly voltage testing for the generator's sealed batteries,
b. monthly conductance testing for sealed batteries;
c. 3-year 4 hour load testing;
d. documentation provided for the last annual fuel sample taken was dated March 8, 2023. In addition, the results of the sampling was not available for review.

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed emergency generator testing/inspection was not completed.

2. Observation made on June 26, 2024, between 2:48 p.m. and 2:56 p.m., revealed the following emergency generator deficiencies:

a. the 2000 kw walk-in generator lacked back-up emergency lighting inside the housing;

b. the emergency generator lacked a labeled remote manual stop station, located outside the housing of the prime mover;

c. the trouble panel did not illuminate when conducting a lamp test of the 2000 kw generator;

d. remote annunciator panels were relocated temporarily during Commons Building (non-healthcare) renovations;

Exit Interview with the Administrator, Director of Environmental Service and Engineering, and the Maintenance Assistance, on June 26, 2024, at 2:00 p.m., confirmed the emergency generator components were not installed or were in inoperable condition.

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Based on an onsite Revisit conducted on August 15, 2024, between 8:45 a.m. and 10:30 a.m., revealed the following:

Item 1. Not Completed. The following testing/inspection reports were not available for both emergency generators:
c. 3-year 4 hour load testing;
d. Documentation provided for the last annual fuel sample taken was dated March 8, 2023. In addition, the results of the sampling was not available for review.

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed the emergency generator testing/inspection was not completed.

Item 2. Not Completed. The following emergency generator deficiencies:
c. The trouble panel did not illuminate when conducting a lamp test of the 2000 kw generator;
d. Remote annunciator panels were relocated temporarily during Commons Building (non-healthcare) renovations;

Exit Interview with the Assistant Maintenance Director on August 15, 2024, at 10:15 a.m., confirmed the emergency generator components were not installed or were in inoperable condition.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 09/24/2024

A. With respect to the specific resident/situation cited:
1 C: Engineering director has scheduled the 3-year 4 hour load testing.

1D: Engineering director has reach out to the community's fuel supplier for documentation for test results.

2C: Per engineering direction, the lighting will be revised and fixed to meet regulation.

2D: This is a temporary location, and will be returned to its permanent location, upon completion of renovation.

B. With respect to how the facility will identify residents/situations for the identified concerns:

Engineering director conducted a comprehensive monthly generator check. In addition, director will provide a comprehensive generator audit training to the engineering department. Audits will be maintained by Engineering Director and NHA.

C. With respect to what systemic measures have been put into place to address the stated concern:

Engineering director or designee will conduct monthly generator audit.

D. With respect to how the plan of correction will be monitored:

At the conclusion of the 3 months, the QAPI (Quality Assurance and Performance Improvement) committee will re-evaluate and initiate any necessary action or extend the review period if needed.

The Administrator is responsible for ensuring implementation and ongoing, compliance with the components of the Plan of Correction and addressing variances that may occur

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