Pennsylvania Department of Health
REHAB AT SHANNONDELL
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 19 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


REHAB AT SHANNONDELL - 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 July 23, 2024, at Rehab At Shannondell, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MEADOWS II - Component: 02 - Tag: 0000

Facility ID #17580201
Component 02
Meadows II

Based on a Medicare/Medicaid Recertification Survey completed on July 23, 2024, it was determined that Rehab At Shannondell 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MEADOWS II - Component: 02 - Tag: 0100

Based on observation and interview, it was determined the facility failed to install carbon monoxide alarms in close proximity to fossil fuel-burning devices, in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings Include:

1. Observations on July 23, 2024 at 11 a.m., revealed the facility failed to install a carbon monoxide alarm in close proximity to gas fired equipment inside the boiler room.

Interview at the exit conference with Maintenance Director on July 23, 2024 at 3:15 pm, confirmed the lack of a carbon monoxide detector.

Plan of Correction - To be completed: 09/30/2024

The carbon monoxide detector was installed, tested, and inspected by Siemens company on Friday, August 16th, 2024.
The Director of Maintenance will in-service the maintenance staff on the importance of carbon monoxide alarms in close proximity to gas fired equipment.
This in-service will be completed by Monday, September 30th, 2024.
The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0100 verifying the carbon monoxide alarms are in close proximity to gas fired equipment.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MEADOWS II - Component: 02 - Tag: 0293

Based on documentation review and interview, it was determined the facility failed to maintain inspection of exit and directional signs, affecting the entire facility.

Findings include:

1. Document review on July 23, 2024, at 10:00 a.m., revealed the faciltiy failed to provide documentation of Exit sign monthly inspection reports.

Interview at the exit conference with the Director of Maintenance on July 23, 2024, at 3:15 p.m., confirmed the lack of monthly testing documentation.

Plan of Correction - To be completed: 09/30/2024

The Director of Maintenance will in-service the maintenance staff on the importance to provide documentation of Exit sign monthly inspection reports.
This in-service will be completed by Monday, September 30th, 2024.
The Director of Maintenance or his designee beginning September 1, 2024, will conduct monthly audits to meet compliance with K 0293 verifying the documentation of Exit sign monthly inspection reports.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MEADOWS II - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas, affecting three of five levels.

Findings include:

1. Observation on July 23, 2024 between 10:30 a.m. and 2:45 p.m, revealed the following hazardous area deficiencies:

a. Basement Housekeeping- door failed to latch;
b. Basement Laundry- door failed to latch;
c. Basement Clean/ Folding- door failed to latch.;
d. Basement Ambulance Entrance - boxes, equipment, oxygen tanks stored. The area was
open to the corridor;
e. 2nd floor C-Wing Oxygen Storage Closet- had damaged door coordinator;
f. 3rd floor C-Wing Housekeeping Storage- door had gap when closed, greater than 1/8";
g. 3rd floor Commons Area - there were approximately 25 boxes storage inside the
conference room;
h. 3rd floor 3C Housekeeping Storage Closet - 1/4" inch gap between the double doors.

Interview at the exit conference with the Maintenance Director on July 23, 2024, at 3:15 p.m, confirmed the above listed inhibiting door issues.

2. Observations on July 23, 2024, at 1:45 p.m., inside the 3rd floor Conference Room revealed approximately 25 boxes of combustible paper documents. This room is not a designated storage area.

Interview at the exit conference with the Maintenance Director on July 23, 2024, at 3:15 p.m, confirmed the storage of combustibles outside of a hazardous storage location.

Plan of Correction - To be completed: 09/15/2024

The Maintenance department will repair and/or resolve the following items:
1.
- The basement housekeeping door latch will be repaired.
- The basement laundry door latch will be repaired.
- The clean/folding door latch will be repaired.
- The basement ambulance entrance area boxes, equipment, and oxygen tanks will be removed.
- The 2nd floor C-wing oxygen storage closet door coordinator will be repaired.
- The 3rd floor housekeeping storage closet door gap will be adjusted to no more than 1/8 inch.
- The 3rd floor Common area Conference room boxes will be removed.
2.
- The 3rd floor Conference room will not be a designated storage area.

These items will be completed by Monday, September 30th, 2024.

The Director of Maintenance will in-service the maintenance staff on the importance of the following requirements:
1.
- The basement housekeeping door is required to latch.
- The basement laundry door is required to latch.
- The clean/folding door is required to latch.
- The basement ambulance entrance shall have no boxes, equipment, and/or oxygen tanks stored. This area is open to the corridor.
- The 2nd floor C-wing oxygen storage closet door coordinator shall be in proper working condition and not damaged.
- The 3rd floor housekeeping storage closet door shall not have a gap of more than 1/8 inch.
- The 3rd floor Common area Conference room shall not have boxes stored in the room.
2.
- The 3rd floor Conference room is a designated storage area.

This in-service will be completed by Monday, September 30th, 2024.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0321.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler system components were maintained free of debris, affecting one of five levels.

Findings include:

1. Observation on July 23, 2024, revealed inside the basement laundry revealed lint and dust build up on sprinkler heads inside the dryer maintenance access room.

Interview at the exit conference with the Maintenance Director on July 23, 2024, at 3:15 p.m, confirmed lint and dust on the sprinkler heads.

Plan of Correction - To be completed: 09/15/2024

The Maintenance department will remove the lint and dust buildup on the sprinkler heads inside the dryer maintenance access room.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance will in-service the maintenance staff on the importance of lint and dust buildup on sprinkler heads.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0353 verifying there is no lint or dust buildup on the sprinkler heads inside the dryer maintenance access room.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Sprinkler System - Out of Service:

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Observations:
Name: MEADOWS II - Component: 02 - Tag: 0354

Based on documentation review and interview, it was determined the facility failed to ensure fire watch procedures were outlined, affecting the entire facility.

Findings Include:

1. Document review on July 23, 2024, at 10:00 a.m., revealed fire watch procedures did not include sprinkler system inoperable or impaired conditions.

Interview at the exit conference with Maintenance Director on July 23, 2024 at 3:15pm confirmed fire watch procedures were incomplete.

Plan of Correction - To be completed: 09/15/2024

The Maintenance department will provide the fire watch procedures that include when the sprinkler system is inoperable or impaired conditions.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance will in-service the maintenance staff on the importance of including when the sprinkler system is inoperable or impaired conditions in the fire watch procedures.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0354.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with smoke tight resistance and positive latching into the frame, affecting one of five levels.

Findings Include:

Observation made on July 23, 2024, at 12:44 p.m., revealed the SPA corridor door was held open by an unauthorized means, a rubber chock, 2nd floor Common Area.

Interview at the exit conference with the Maintenance Director on July 23, 2024, at 3:15 p.m, confirmed the corridor door obstruction.

Plan of Correction - To be completed: 09/15/2024

door on July 23, 2024.
This was completed by Tuesday, July 23rd, 2024.
The Director of Maintenance will in-service the maintenance staff on the importance of removing any unauthorized means including a rubber chock from holding open the Spa doors.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0363 verifying there is no unauthorized means, including rubber chocks of holding the Spa doors open.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure smoke barrier doors were maintained to resist the passage of smoke, affecting two of fourteen smoke zones.

Findings include:

Observation on July 23, 2024, at 1:05 p.m., revealed the 3rd floor smoke doors into C- Wing failed to latch. The doors were equipped with latching hardware.

Interview at the exit conference with Maintenance Director on July 23, 2024 at 3:15pm confirmed the smoke doors were not smoke tight.

Plan of Correction - To be completed: 09/15/2024

The Maintenance department will repair the latching device on the 3rd floor C-wing smoke doors.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance will in-service the maintenance staff on the importance of the smoke doors closing and latching when equipped with latching hardware.
This will be completed by Monday, September 30th, 2024.
The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0374 verifying all the smoke doors close and latch.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results

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: MEADOWS II - Component: 02 - Tag: 0521

Based on document review, observation and interview, it was determined the facility failed to maintain Air-Conditioning and Ventilating Systems, affecting the entire facility.

Finding include:

1. Documentation reviewed on July 23, 2024, between 8:30 a.m. and 11:30 a.m., revealed documentation verifying 4-year inspection/exercising of fire/smoke dampers was not available for review at the time of survey.

Interview at the exit conference with the Director of Maintenance on July 23, 2024, at 3:15 p.m., confirmed inspection/testing of mechanical equipment was not available.

2. Observation made on July 23, 2024, at 11:15 a.m., revealed the basement Ambulance Entrance Vestibule supply grill flex duct was not connected above the suspended ceiling.

Interview at the exit conference with the Director of Maintenance on July 23, 2024, at 3:15 p.m., confirmed the incomplete duct connection.

3. Observation made on July 23, 2024, at 12:49 p.m., revealed inside the 2nd fl Nurses Closet B Wing, the ceiling grill had a large buildup of soot material, inhibiting the passage of airflow.

Interview at the exit conference with the Director of Maintenance on July 23, 2024, at 3:15 p.m., confirmed the obstruction to air flow.

Plan of Correction - To be completed: 09/15/2024

1. The Director of Maintenance will provide the 4-year inspection/exercising of fire/smoke dampers for review at the time the surveyors arrive.

Life Safety Services is scheduled on to perform the 4-year inspection/exercising of the fire/smoke dampers.
The 4-year inspection/exercising of the fire/smoke dampers report will be available at the conclusion of the inspection
The Director of Maintenance will in-service the maintenance staff on the importance of the 4-year inspection/exercising of fire/smoke dampers

The Director of Maintenance or his designee beginning November 1st, 2024, will conduct monthly audits to meet compliance with K 0521.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

2. The Maintenance department will connect the supply grill flex duct above the suspended ceiling in the basement Ambulance vestibule.

The Director of Maintenance will in-service the maintenance staff on the importance of the supply grill being connected above the suspended ceiling in the basement Ambulance vestibule.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0521.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

3. The Maintenance department will clean the ceiling grill that had a large buildup of soot material, inhibiting the passage of air flow in the 2nd floor Nurses closet B-wing.

The Director of Maintenance will in-service the maintenance staff on the importance of the ceiling grill that had a large buildup of soot material, inhibiting the passage of air flow in all the Nurse's closets.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0521.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MEADOWS II - Component: 02 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to provide detailed reporting information for each of the monthly fire drills, affecting twelve of twelve reports.

Findings include:

1. Documentation review on July 23, 2024, at 10:00 a.m., revealed the facility lacked sign-off sheets recording staff participation in fire drill procedures during monthly fire drills. Fire drills should be scheduled on a random basis to ensure personnel in health care facilities are drilled not less than once in each 3-month period.

Exit interview at with Maintenance Director on July 23, 2024 at 3:45 p.m., confirmed fire drill reports were incomplete.

Plan of Correction - To be completed: 09/15/2024

The Director of Maintenance will provide the sign-off sheets recording staff participation in fire drill procedures during monthly fire drills beginning August 1st, 2024.
The Director of Maintenance will in-service the maintenance staff on the importance of providing the sign-off sheets recording staff participation in fire drill procedures during monthly fire drills beginning August 1st, 2024.

The Director of Maintenance or his designee will conduct monthly audits to meet compliance with K 0712 verifying the sign-off sheets recording staff participation in fire drill procedures during the monthly fire drills.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results

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: MEADOWS II - Component: 02 - Tag: 0761

Based on observation, document review and interview, it was determined the facility failed to ensure fire-rated doors and assemblies were inspected annually, affecting the entire facility.
Findings include:
1. Document review on July 23, at 10:00 a.m., revealed the facility could not provide documentation on the annual inspection for fire-rated doors.
Exit interview with the Administrator and Facility Director, on July 23, 2024, at 3:15 p.m., confirmed the lack of documentation.

2. Observation on July 23, at 12:25 p.m., revealed one of two doors in the fire rated doorway at the connection to the A-wing had missing hinge screws.
Exit interview with the Director of Maintenance on July 23, 2024, at 3:15 p.m., confirmed the missing hinge screws.

Plan of Correction - To be completed: 09/15/2024

1. The Maintenance department will perform the annual inspection of the fire-rated doors.

The Director of Maintenance will in-service the maintenance staff on the importance of the annual inspection of the fire-rated doors.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0761 verifying all the fire-rated doors have been inspected.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

2. The Maintenance department will install the missing hinge screws on the (1st floor) fire-rated doorway at the connection to the A-wing area.

The Director of Maintenance will in-service the maintenance staff on the importance of the missing hinge screws in all the fire-rated doors.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0761 verifying all the fire-rated doors have been inspected and no hinge screws are missing.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

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

Observations:
Name: MEADOWS II - Component: 02 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintained required testing of electrical receptacles, affecting the entire facility.

Findings include:

1. Document review on July 23, 2024, at 10:30 a.m., revealed the facility was unable to provide documentation showing annual receptacle testing.

Interview at the exit conference with the Director of Maintenance on July 23, 2024, at 3:45 pm, confirmed the documentation was unavailable at time of survey.

Plan of Correction - To be completed: 09/15/2024

The Maintenance department will perform the annual receptacle testing.

The Director of Maintenance will in-service the maintenance staff on the importance of the annual receptacle testing.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0914 verifying the receptacles are being tested annually.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0918

Based on document review, observation and interview, it was determined the facility failed to maintain and install emergency generator components, affecting the entire facility.

Findings include:

1. Document review on July 23, 2024, at 9:30 a.m., revealed the facility could not provide documentation of the Annual fuel quality test.

Exit Interview with the Maintenance Director on July 23, 2024, at 3:45 p.m, confirmed the lack of testing and documentation.

2. Observation on July 23, 2024, at 10:30 a.m, revealed the basement electrical room that houses the automatic transfer switch (ATS) for the generator did not have a battery back-up light to illuminate the room if a power loss occurs.

Exit Interview with the Maintenance Director on July 23, 2024, at 3:45 p.m, confirmed back-up lighting was not provided.

Plan of Correction - To be completed: 09/15/2024

1. The Maintenance department will perform the annual fuel quality test.

The Director of Maintenance will in-service the maintenance staff on the importance of the annual receptacle testing.

The Director of Maintenance or his designee beginning October 1st, 2024, will conduct monthly audits to meet compliance with K 0914 verifying the receptacles are being tested annually.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.
2. The Maintenance department will install a battery back-up light to illuminate the basement electrical room if the normal power & the emergency power loss occurs.

The Director of Maintenance will in-service the maintenance staff on the importance of illuminating the basement electrical room should the normal power & an emergency power loss occurs.
The Director of Maintenance or his designee will conduct monthly audits to meet compliance with K 0918 verifying the back-up battery powered emergency light fixture operation.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical devices, affecting one of five levels within this facility.

Findings include:

1. Observation made on July 23, 2024, at 11:40 am, revealed inside the basement Boiler Room, extension cords were in use to operate floor drying fans due to leaking boiler equipment under repair.

Interview at the exit conference with Maintenance Director on July 23, 2024 at 3:15 pm, confirmed the use of extension cords to power drying equipment in the boiler room.

Plan of Correction - To be completed: 09/15/2024

The Director of Maintenance removed the extension cords that were in use to operate the floor drying fans due to leaking boiler equipment under repair on July 23, 2024.

The Director of Maintenance will in-service the maintenance staff on the importance of removing any extension cords that are in use to operate floor drying fans due to leaking boiler equipment under repair.

The Director of Maintenance or his designee will conduct monthly audits to meet compliance with K 0920 verifying there is no extension cords that are in use to operate floor drying fans due to leaking boiler equipment under repair.
These audits will continue until December 31st, 2024, when at that time the QA Committee will decide if the audits should continue, or end based on the results.

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