Nursing Investigation Results -

Pennsylvania Department of Health
MEADOWVIEW REHABILITATION AND NURSING CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MEADOWVIEW REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  38 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.
MEADOWVIEW REHABILITATION AND 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 August 29, 2019, at Meadowview Rehabilitation And Nursing Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID# 183202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on October 16, 2018, it was determined that Meadowview Rehabilitation and 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 two-story, Type III (200), unprotected ordinary construction, which 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: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation, document review, 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. Observation and documentation reviewed August 29, 2019, between 8:15 a.m. and 2:30 p.m., revealed documentation was unavailable verifying staff in-servicing and an updated emergency/disaster manual that included the type of carbon monoxide detection system provided and emergency procedures.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the carbon monoxide detection system required updated policies and procedures.
















 Plan of Correction - To be completed: 10/23/2019

The locations of the Carbon Monoxide detectors in the building are as follows:
2 hardwired units in boiler room (above the boilers). These are connected to the alarm system and the alarm would sound throughout the entire building.
1 battery operated detector outside of boiler rm. In the service hallway
1 battery operated detector outside laundry in the service hallway
1 battery operated detector outside of Dietary in the hallway
The battery operated carbon monoxide detectors will be made to alert in an area that is staffed 24-7 in the building thru a wireless interconnected detector with a 10 year lithium battery. Maintenance will perform monthly checks to ensure proper operation.

Staff will be in-serviced and updated on the emergency/disaster manual that included the type of carbon monoxide detection system provided and emergency procedures.

Administrator or designee will ensure this is part of the annual training for all current staff and also part of new hire orientation.
NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting the entire facility.

Findings include:

1. Observation and documentation reviewed on August 29, 2019, between 8:15 a.m. and 2:30 p.m., revealed the facility had been classified as a two-story, Type III (200), unprotected ordinary construction, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type, by one story.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the building exceeds the maximum allowable story height.











 Plan of Correction - To be completed: 10/23/2019

Facility requests that the PA Department of Health, Life Safety Division, uses facility FSES plan on file.
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 maintain the means of egress free of obstruction, affecting 1 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 2:04 p.m., revealed the Special Locking Arrangement (SLA) at the exit discharge door did not manually release when the keypad was tested, C Wing, upper level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed there was an obstruction to exiting.








 Plan of Correction - To be completed: 10/23/2019

The Special Locking Arrangement (SLA) at the C wing exit discharge door was made to manually release when the keypad was tested.

Weekly audits will be performed by Maintenance staff on all SLA's to ensure they release when code is entered into the keypad.

Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
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 protection of vertical openings between floors, affecting 2 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 1:07 p.m., revealed there was trash (debris) at the bottom of the elevator shaft, E Wing, lower level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed there was combustible debris.




 Plan of Correction - To be completed: 10/23/2019

The trash (debris) at the bottom of the elevator shaft, E Wing, lower level was removed.

The elevator contractor will be notified of removing trash during routine elevator inspections.
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 smoke resistant separation from other spaces, in sprinklered locations, affecting 3 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 11:48 a.m., revealed the following deficiencies at the corridor double doors leading to the central supply maintenance area, Service Wing, lower level:

a. the double doors did not latch into their frame when tested;
b. there was a manual flush installed on the inactive leaf, in lieu of automatic self latching
hardware;
c. the inactive leaf lacked self-closing hardware.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the hazardous area door deficiencies named above.


2. Observation made on August 29, 2019, between 11:52 a.m. and 1:15 p.m., revealed the following hazardous area doors would not latch into their frames:

a. 11:52 a.m., housekeeping room corridor door, Service Wing, lower level;
b. 1:15 p.m., medical supplies room corridor door, B Wing, upper level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the hazardous area doors required adjustment.


3. Observation made on August 29, 2019, at 1:22 p.m., revealed there was a large gap near the latch, between the trash room corridor door and its frame, A Wing, upper level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the hazardous area door was not smoke tight in the frame.











 Plan of Correction - To be completed: 10/23/2019

The following was done to the corridor double doors leading to the central supply maintenance area, Service Wing, lower level:
a. the double doors were made to latch into their frame when tested;
b. An automatic self-latching hardware was installed on the inactive leaf
c. the inactive leaf had self-closing hardware installed.

The housekeeping room corridor door and the medical supplies room on B wing were made to latch into their frames.
The large gap near the latch on the A wing trash room corridor door was repaired, A Wing.

The Maintenance Director was in serviced on the importance of self-latching hardware.

Quarterly audits will be performed by Maintenance staff on the all double doors to ensure self-latching and that all hazardous doors latch to their frames and no large gaps exists.
Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were installed per regulations, affecting 1 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 1:37 p.m., revealed the ABHR inside the Business Office was installed above the light switch, A Wing, upper level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the ABHR was exposed to an ignition source.






 Plan of Correction - To be completed: 10/23/2019

The ABHR inside the Business Office was moved so not to be installed above the light switch.

Maintenance staff will be in-serviced on proper placement of ABHR's

Monthly audits will be performed by the Maintenance Director to ensure proper placement of ABHR's.

Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
NFPA 101 STANDARD Corridor - 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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain positive latching of doors along the corridor means of egress, affecting 2 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, between 12:30 p.m. and 12:40 p.m., revealed the followiong corridor doors were partially impeded from closing:

a. 12:30 p.m., resident room 5 corridor door dragged the floor when in the open position, E Wing, lower level;
b. 12:40 p.m., resident room 2 door dragged the floor when closing, E Wing, lower level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the corridor doors required adjustment to close into its frame.


2. Observation made on August 29, 2019, at 1:52 p.m., revealed resident room corridor door 17 was held open by a trash can. The door hinges would not allow the door to remain in the open position, C Wing, upper level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the corridor door was impeded from closing into its frame.





 Plan of Correction - To be completed: 10/23/2019

The doors on room E5 and E2 were made not to dragged the floor when in the open position;
The trash can blocking the door on room C17 was removed. The door hinges were made to allow the door to remain in the open position.

Quarterly audit will be performed by Maintenance Director to ensure no doors drag the floor when opening or closing.

Radom weekly audits will be performed by Maintenance staff to ensure that no doors are being held open with trash cans.

Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation, document review and interview, it was determined the facility failed to maintain the requirements for smoke compartmentation, affecting 1 of seven smoke zones within this facility.

Findings include:

1. Observation and documentation review made on August 29, 2019, between 8:15 a.m. and 2:30 p.m., revealed the ground floor, E-wing, front corridor smoke compartment exceeded the maximum allowance of 22,500 square feet.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the smoke compartment exceeded the maximum allowable square footage.









 Plan of Correction - To be completed: 10/23/2019

Facility requests that the PA Department of Health, Life Safety Division, uses facility FSES plan on file.
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 document review and interview, it was determined the facility failed to conduct fire drills per regulations, affecting 3 of twelve drills.

Findings Include:

1. Documentation reviewed on August 29, 2019, between 8:15 a.m. and 10:45 a.m., revealed fire drill documentation indicated 3rd shift fire drills were conducted around the same time frames:

December 26, 2018 @ 3:30 a.m.
June 21, 2019 @ 3:30 a.m.
September 21, 2019 @ 3:00 a.m.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed fire drills were not conducted at various times.








 Plan of Correction - To be completed: 10/23/2019

The maintenance director was in serviced on not conducting fire drills around the same time frames:

Quarterly audits will be performed by the administrator to ensure fire drills are not in the same time frames.
Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
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 door assemblies with a fire resistance rating, affecting 1 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 1:00 p.m., revealed the stair door by room 20 had approximately 9 small holes, D Wing, lower level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the integrity of the rated door was not maintained.






 Plan of Correction - To be completed: 10/23/2019

The stair door by room D20 was repaired using an approved method for fire rated doors.

Quarterly audits will be performed by Maintenance staff to ensure no doors have holes.
Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
NFPA 101 STANDARD Electrical Systems - Receptacles: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.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain protection of electrical receptacles, affecting 1 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 12:29 p.m., revealed the hydrocollator inside Physical Therapy lacked ground fault protection from wet conditions.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the electrical receptacle was not protected.








 Plan of Correction - To be completed: 10/23/2019

The hydrocollator inside Physical Therapy was made to have ground fault protection from wet conditions.

Physical Therapy staff was in serviced on the importance of the hydrocollator having GFCI protection.

Monthly audits will be performed by Maintenance staff to ensure the hydrocollator is plugged into a GFCI.

Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices, affecting 1 of seven smoke compartments.

Findings include:

1. Observation made on August 29, 2019, at 1:50 p.m., revealed there was medical equipment (nebulizer) plugged into a surge protector inside resident room 1, C Wing, upper level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed the unauthorized use of an electrical device.





 Plan of Correction - To be completed: 10/23/2019

The medical equipment (nebulizer) in room C1 was made not to be plugged into a surge protector.

Nursing staff was in serviced on not using surge protectors for medical equipment.

Month audits will be performed by Maintenance staff to ensure no medical equipment is plugged into a surge protector.

Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain proper storage of gas equipment, affecting 1 of seven smoke compartments.

Findings Include:

1. Observation made on August 29, 2019, at 12:25 p.m., revealed there were 5 Type E oxygen cylinders stored near boxes and a light switch, inside the physical therapy closet, E Wing, lower level.

Interview at the exit conference with the Facility Administrator, the Regional Director of Facilities, and the Director of Maintenance on August 29, 2019, at 2:30 p.m., confirmed gas storage was stored near combustible materials and an ignition source.









 Plan of Correction - To be completed: 10/23/2019

The 5 Type E oxygen cylinders stored near boxes and a light switch, inside the physical therapy closet was moved so not to be stored near boxes or light switches.

Staff will be in serviced on proper placement of Type E oxygen cylinders.

Random weekly audits will be performed by Maintenance Staff to ensure the proper placement of Type E oxygen cylinders.

Results of audits will be reviewed/ reported to QA Committee to determine trends, compliance. QA Committee will determine need for continuance of audits.

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