Nursing Investigation Results -

Pennsylvania Department of Health
REGINA COMMUNITY NURSING CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
REGINA COMMUNITY NURSING CENTER
Inspection Results For:

There are  35 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.
REGINA COMMUNITY NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 21, 2020, it was determined Regina Community Nursing Center was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(a)(3) REQUIREMENT EP Program Patient Population: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.
[(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 the following:]

(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*[For LTC facilities at 483.73(a)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]
Observations:
Name: - Component: -- - Tag: 0007

Based on document review and interview, it was determined the facility failed to maintain an emergency preparedness plan that addressed persons at-risk, affecting the entire facility.

Findings include:

1. Document review on January 21, 2020, at 7:45 a.m., revealed the facility failed to maintain an emergency preparedness plan that addressed persons at-risk.
Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Plan will be updated to address persons at risk. The Emergency Preparedness Plan will be reviewed and updated annually. The Maintenance Director and Administrator are to monitor, review and update manual as needed.

483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and Patients: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.
[(b) Policies and procedures. [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 every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015

Based on document review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures that addressed subsistence needs for staff and residents, affecting the entire facility.

Findings include:

1. Document review on January 21, 2020, at 7:45 a.m., revealed the facility failed to provide documentation in the emergency preparedness plan that addressed subsistence needs for staff and residents during an emergency as follows:

a. Food
b. Sewage and waste disposal.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Manual will be updated to identify and policies and procedures for subsistence needs to include:
A. Food
B. Sewage and waste disposal
The Staff will be in-serviced on the updated sections.
The Maintenance Director and Administrator are to monitor, review and update manual as needed. 3/13/2020

483.73(c)(1) REQUIREMENT Names and Contact Information: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.
[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:]
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at 482.15(c) and CAHs at 485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

Based on document review and interview, it was determined the facility failed to develop
an Emergency Preparedness Communication Plan that contained all the required contact information, affecting the entire facility.

Findings include:

Document review on January 21, 2020, at 7:45 a.m., revealed the facility's Emergency Preparedness Communication Plan did not contain the contact information for resident's physicians.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Manual has been updated to include contact information for resident's physicians. The Staff will be in-serviced on the updated section.
The Director of Nursing and Administrator are to monitor, review and update manual as needed. 3/13/2020

483.73(c)(2) REQUIREMENT Emergency Officials Contact Information: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.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at 483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at 483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.
Observations:
Name: - Component: -- - Tag: 0031

Based on document review and interview, it was determined the facility failed to develop
an Emergency Preparedness Communication Plan that contained all the required contact information, affecting the entire facility.

Findings include:

Document review on January 21, 2020, at 7:45 a.m., revealed the facility's Emergency Preparedness Communication Plan did not contain the contact information for the Office of the State Long-Term Care Ombudsman.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Manual has been updated to include contact information for The Office of the State Long Term Care Ombudsman. The Staff will be in-serviced on the updated section.
The Director of Nursing and Administrator are to monitor, review and update manual as needed. 3/13/2020

483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan that included a means of providing information about the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting the entire facility.

Findings include:

1. Document review on January 21, 2020, at 7:45 a.m., revealed the facility lacked an Emergency Preparedness plan that included a means of providing information about the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Manual will be updated to provide information on the facility's needs and ability to provide assistance to the authority having jurisdiction including occupancy.
The facility has a Mutual Aide Agreement in place with the Pennsylvania Health Care Coalition in the event of an emergency, internal or external of the facility.
The staff will be in-serviced during the annual Emergency Preparedness training on the updated sections.
The Maintenance Director and Administrator are to monitor, review and update manual as needed. 3/13/2020

483.73(d) REQUIREMENT 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.
*[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, CAHs at 486.625, "Organizations" under 485.727, CMHCs at 485.920, OPOs at 486.360, 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 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 document 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 January 21, 2020, at 7:45 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Manual will be updated to identify the policies and procedures for training all new and existing staff.
All staff will be in-serviced on the Emergency Preparedness Manual and annually thereafter.
The Director of building Services and the Administrator will monitor, review and update manual as needed. 3/13/2020


483.73(d)(1) REQUIREMENT EP Training Program: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.
*[For RNCHIs at 403.748, ASCs at 416.54, Hospitals at 482.15, ICF/IIDs at 483.475, HHAs at 484.102, "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 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 document 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 January 21, 2020, at 7:45 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.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Emergency Preparedness Manual will be updated to identify the policies and procedures for training all new and existing staff.
All staff will be in-serviced on the Emergency Preparedness Manual and annually thereafter.
The Director of building Services and the Administrator will monitor, review and update manual as needed. 3/13/2020

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



Facility ID #182002
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on January 21, 2020, it was determined Regina Community Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive structure, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure paths of egress were continuously maintained free of obstructions for full use in case of an emergency, affecting one of three levels within the facility.

Findings include:

Observation made on January 21, 2020, at 11:25 a.m., revealed the 1st floor B-wing egress corridor was impeded by multiple carts.
Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the egress corridor was impeded.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The carts on 1st floor B-wing have been removed. Maintenance staff will receive in-service training on the importance of maintaining obstruction free mean of egress. Director of Building Services are to monitor for compliance. 3/13/2020
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain exit stairways were free of storage, affecting one of three stair tower enclosures within the facility.
1. Observation on January 21, 2020, at 11:22 a.m., revealed a cart was being stored inside the 1st floor B-1 stair tower.
Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed a cart was being stored inside the stair tower.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The cart was removed immediately. The staff member responsible for the cart has received additional training the importance of maintaining obstruction free mean of egress. The Director of Building Services to monitor for compliance. 3/13/2020
NFPA 101 STANDARD Vertical Openings - 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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of deck slabs between floors, affecting two of three levels within the facility.

Findings include:

Observation made on January 21, 2020, at 1:39 p.m., revealed inside the 1st floor conference room, above the suspended ceiling, there was an approximately 8 inch in diameter unsealed vertical penetration through the rated deck slab, near the smoke barrier wall.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed there was an unsealed vertical penetration in the rated deck slab penetration.




 Plan of Correction - To be completed: 02/21/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The vertical penetration inside the first floor conference room was corrected with approved through penetration fire stop material system C-AJ-1427.
Maintenance department was in-serviced regarding maintaining the proper fire resistance rating of the smoke barrier walls, and properly using through penetration fire stop systems.
Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 2/21/2020

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of doors to hazardous areas, affecting two of 10 smoke zones within the facility.

Findings include:

1. Observation made on January 21, 2020, at 11:44 a.m., revealed there were holes in the rated double doors to the 1st floor laundry room.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed there were holes in the rated doors.

2. Observation made on January 21, 2020, at 11:50 a.m., revealed the door to the 1st floor maintenance storage room was missing a self closure.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the door was missing a self-closing device.




 Plan of Correction - To be completed: 02/27/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The holes in the metal double doors for the laundry room were sealed with metal screws on 2/12/2020. A self closure will be added to the fire rated door to Maintenance Storage room.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

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

Findings include:

1. Document review on January 21, 2020, at 7:45 a.m., revealed the annual fire alarm inspection report dated May 20, 2019, indicated the following fire alarm system deficiencies on page 9 of the report:

a. The batteries in the main fire alarm failed load test and needed to be replaced.
b. The horn/strobe on the 1st floor, in the hallway, by the loading dock failed and needed to be replaced.

The facility could not provide documentation the fire alarm system deficiencies listed above had been repaired.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 02/12/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The Fire alarm deficiencies reported on page 9 of the May 20,2019 inspection were repaired. Documentation of completed work can be found on the service invoice dated in September 2019. A copy of the invoice will be provided. In the future all repair invoices will be filed along with the corresponding Inspection report. Director of Building Services will monitor for compliance. Any deficient findings will be reported to the QAPI committee. 2/12/2020
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Observation made on January 21, 2020, at 11:25 a.m., revealed, inside the 1st floor maintenance shop, the sprinkler risers were blocked by a cart, a chair and a plastic five gallon bucket. There was also metal pipe stock bundle leaning on the risers.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the risers were blocked.
2. Observation made on January 21, 2020, at 1:15 p.m., revealed the fire department connection located on the exterior of the facility was missing identifying signage.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the signage was missing.

3. Observation made on January 21, 2020, at 1:25 p.m., revealed, on the first floor, inside a closet located within the owner's office, there was storage on a shelf approximately two inches below a ceiling mounted sprinkler.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the sprinkler was obstructed.





 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The items that were blocking the sprinkler head were moved immediately. Maintenance staff will receive in-service training on the importance of maintain free access to the sprinkler riser. Signage for the exterior stand pipes has been ordered and will be installed. Items on the shelf inside the closet will be moved to allow for proper clearance. Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 3/13/2020
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the smoke barrier walls, affecting two of 10 smoke zones within the facility.

Findings include:

1. Observation made on January 21, 2020, between 1:37 p.m. and 1:46 p.m., revealed unsealed horizontal penetrations of the smoke barrier wall in the following locations:

a. 1:37 p.m., 1st floor, inside the conference room, above the suspended ceiling, around a data wire and an electrical armor cable, both sides of smoke barrier wall.
b. 1:46 p.m., 1st floor, inside the women's bathroom near the conference room, above the suspended ceiling, there was a broken section of smoke barrier wall behind an HVAC duct.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the unsealed penetrations in the above named locations.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The penetration inside the first floor conference room and the women's bathroom were corrected with approved through penetration fire stop material system C-AJ-1427.
Maintenance department was in-serviced regarding maintaining the proper fire resistance rating of the smoke barrier walls, and properly using through penetration fire stop systems.
Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 3/13/2020

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure that smoke barrier doors fully closed to resist the passage of smoke, affecting two of 10 smoke zones within the facility.

Findings include:

Observation made on January 21, 2020, at 1:40 p.m., revealed the 1st floor smoke barrier cross corridor doors near the conference room failed to fully close.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the doors failed to fully close.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The smoke barrier doors on first floor near conference room will be adjusted to allow them to fully close. Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 3/13/2020
NFPA 101 STANDARD HVAC - Any Heating Device:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0522

Based on observation and interview, it was determined the facility failed to maintain heating units were free of combustible materials, affecting one of 10 smoke zones within the facility.

Findings include:

1. Observation made on January 21, 2020, at 2:04 p.m., revealed, inside the 2nd floor resident room #213, combustible linens were stored on top of a heating unit.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the linens were on top of a heater unit.




 Plan of Correction - To be completed: 02/21/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The linens that were placed on top of the heating unit in room 213 were removed. The CNA responsible for placing the items on the unit will receive additional training regarding the need to keep heating units free from combustible items. Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 2/21/2020
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on interview and document review, it was determined the facility failed to ensure that one of four required second shift, quarterly fire drills were conducted within the facility.

Findings include:

Interview and document review on January 21, 2020, at 7:45 a.m., revealed the facility could not provide documentation a 2nd shift fire drill had been conducted during the third quarter of 2019.
Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 02/21/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The documentation for the 2nd shift fire drill for the third quarter was misfiled. The report has been filed along with the other drill reports. The staff member responsible for the incorrect action will receive additional training on handling completed drill reports. Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 2/21/2020
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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 observation and interview, it was determined the facility failed to maintain rated fire door assemblies, affecting the entire facility.

Findings include:
1. Document review on January 21, 2020, at 7:45 a.m., revealed the facility could not provide documentation that the deficiencies for the following door numbers listed in the facility's 12/18/19 door inspection report were corrected:

1-2; 1-3; 1-4/149; 1-5; 1-6/134; 1-7/139; 1-8; 1-9/136A; 1-10/138B; 1-11/138A; 1-12/136B; 1-13; 1-14; 1-15; 1-16; 1-17; 1-18; 1-19; 1-20; 1-21; 1-22; 1-23; 1-24; 2-1; 2-2; 2-3; 2-4; 3-1; 3-2; 3-3; 3-4.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the deficient doors listed in the inspection report had not been repaired.




 Plan of Correction - To be completed: 03/13/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.
The facility will have the outside vendor return to provide a more recent and accurate door inspection report and develop a plan of action to make repairs to doors that may be non compliant. Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 3/13/2020
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to ensure there was a Natural Gas Reliability Letter available; failed to ensure the facility's emergency generator was inspected and exercised, affecting the entire facility.

Findings include:
1. Document review on January 21, 2020, at 7:45 a.m., revealed the facility could not provide the following emergency generator documentation:

a) Natural Gas Reliability Letter from the supplier.
b) 3-Year, 4-Hour emergency generator exercise had not been performed within the previous 36 months.
c) Weekly visual checks for weeks of 5/12/19, 7/21/19, 8/11/19, 11/11/19 and 11/18/19.

Interview at the exit conference with the Administrator and Maintenance Supervisor on January 21, 2020, at 3:05 p.m., confirmed the documentation listed above was unavailable.




 Plan of Correction - To be completed: 02/21/2020

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.

The facility does have a Natural Gas Reliability letter from the supplier as part of the Emergency Preparedness manual. The 3 year , 4 hour emergency generator exercise was conducted on February 11, 2020. This exercise will be added to the preventive Maintenance Program to comply with the requirement. Maintenance staff will receive additional training on proper documentation of the visual checks that are conducted each week. Director of Building Services will monitor monthly x 3 and report compliance to the Quarterly QAPI committee. 2/21/2020

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