Nursing Investigation Results -

Pennsylvania Department of Health
CRAWFORD COUNTY CARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CRAWFORD COUNTY CARE 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.
CRAWFORD COUNTY CARE 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 24, 2020, it was determined that Crawford County Care Center, was not in compliance with the requirements of 42 CFR 483.73.





 Plan of Correction:


483.73(a) REQUIREMENT Develop EP Plan, Review and Update Annually: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.
The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.

The emergency preparedness program must include, but not be limited to, the following elements:

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

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

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

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 24, 2020, at 9:15 a.m., revealed at the time of the survey, the facility lacked an Emergency Preparedness Plan with written documentation of facility policies annual review.

Interview with the maintenance supervisor on January 24, 2020, at 9:15 a.m., confirmed the Emergency Preparedness Plan did not include the above element.






 Plan of Correction - To be completed: 03/16/2020

An ad hoc Quality Assurance Process Improvement committee meeting will be held to review Emergency Preparedness policies and procedures. All recommended changes will be completed and reviewed at a full Quality Assurance Process Improvement meeting. Annual review will be held thereafter to assure compliance.
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, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 24, 2020, between 9:20 a.m. and 9:21 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes:
a. (9:20 a.m.) sewage and waste disposal agreements;
b. (9:21 a.m.) medical supplies agreement.

Interview with the maintenance supervisor on January 24, 2020, at 9:21 a.m., confirmed the Emergency Preparedness Plan did not include the above elements.







 Plan of Correction - To be completed: 03/16/2020

A sewage and waste agreement is being developed with Powell's Sanitation.
An emergency medical supply agreement has been executed with Medline Industries, Inc.

483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with 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.
*[For ICF/IIDs at 483.475(c):] [(c) The ICF/IID 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.] The communication plan must include all of the following:

*[For LTC Facilities at 483.73(c):] [(c) The LTC 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 annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 24, 2020, at 9:29 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes documentation of information for the Emergency Preparedness Plan shared with residents' families or representatives.

Interview with the administrator on January 24, 2020 at 9:29 a.m., confirmed the Emergency Preparedness Plan did not include the above element.







 Plan of Correction - To be completed: 03/16/2020

A document outlining the Emergency Preparedness Plan has been developed to share with residents, families or responsible parties. The outline of the Emergency Preparedness Plan has been added to the admission packet to inform all new residents, families or responsible parties of the plan.
A letter outlining the Emergency Preparedness Plan will be sent to all current residents, families or responsible parties.
483.73(d) REQUIREMENT EP Training and Testing: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.
*[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, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 24, 2020, at 9:40 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes documentation of all staff having emergency preparedness training annually.

Interview with the administrator on January 24, 2020, at 9:40 a.m., confirmed the Emergency Preparedness Plan did not include the above element.







 Plan of Correction - To be completed: 03/16/2020

Emergency Preparedness training will be completed for all staff on February 19 and 20, 2020 and annually thereafter. The Nursing Home Administrator will assure training is scheduled annually.
483.73(d)(2) REQUIREMENT EP Testing Requirements:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
*[For RNCHI at 403.748, ASCs at 416.54, HHAs at 484.102, CORFs at 485.68, OPO, "Organizations" under 485.727, CMHC at 485.920, RHC/FQHC at 491.12, ESRD Facilities at 494.62]:

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

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

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

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

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

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

*[For OPOs at 486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on January 24, 2020, at 9:45 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes documentation of a second full-scale exercise, table top, or actual event at the time of the survey.

Interview with the administrator on January 24, 2020, at 9:45 a.m., confirmed the Emergency Preparedness Plan did not include the above element.





 Plan of Correction - To be completed: 03/16/2020

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and citations listed on the statement of deficiencies. Crawford County Care Center maintains that the alleged deficiencies do not individually or collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render care as prescribed by regulation. The plan of correction shall operate as Crawford County Care Centers written credible evidence of compliance. By submitting this plan of correction, Crawford County Care Center does not admit to the accuracy of the deficiencies. The plan of correction is not meant to establish any standard of care, contract, obligation, or position and reserves all rights to raise possible contentions and defenses civil criminal claim, action or proceeding.
The Administrator, Director of Nursing and Director of Environmental Services will develop and implement two full scale exercises, as well as a table top exercise to be held in 2020. Dates and outcomes observed from the exercises will be reviewed and reported to the Quality Assurance Process Improvement committee for further review and recommendations.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 193002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 24, 2020, it was determined that Crawford County Care 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 one-story, Type V (111), protected, wood frame building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview, the facility failed to maintain the required regulations set forth by Pennsylvania Act 48 for one of one carbon monoxide detector policy.

Findings include:

1. Document review on January 24, 2020, at 9:10 a.m., revealed the facility lacked a documented carbon monoxide detector policy.

Interview with the maintenance supervisor on January 24, 2020, at 9:10 a.m., confirmed the above carbon monoxide detector policy was not available at the time of the survey.





 Plan of Correction - To be completed: 03/16/2020

The carbon monoxide detector policy was located and reviewed at the Quality Assurance Process Improvement committee meeting January 29, 2020. The policy has been added to the Disaster Manual.
NFPA 101 STANDARD Building Construction Type and Height: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.
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 and interview, the facility failed to maintain building construction in one of eight smoke compartments.

Findings include:

1. Observation on January 24, 2020, at 11:50 a.m., revealed an unsealed square opening in the fire-rated monolithic (drywall) ceiling assembly, in the Century Unit corridor, above the recessed light, between the activity and family rooms.

Interview with the maintenance supervisor on January 24, 2020, at 11:50 a.m., confirmed the above unsealed opening in the fire-rated ceiling assembly.





 Plan of Correction - To be completed: 03/16/2020

The unsealed opening in the ceiling assembly on the Century Unit corridor was repaired Monday January 20, 2020.
A whole house audit of potential areas of penetration will be completed, to assure no additional areas of penetration are detected.
Routine inspections will be entered in to the TELS electronic work order system to continue observations and complete necessary repair on an ongoing basis.
NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined that the facility failed to maintain means of egress, free of obstructions to the full use, in case of emergency, per NFPA 101-7.1.10 and S&C Letter 05-38, at one of one courtyard exit.

Findings include:

1. Observation on January 24, 2020, at 1:30 p.m., revealed the Memory Garden Courtyard exit, had the following deficiencies:
a. the exit lacked a hard-packed walking surface, from the exit gate to a public way (driveway or parking lot);
b. the exit gate did not display exit signage;
c. the exit gate was padlocked from the outside.

Interview with the maintenance supervisor on January 24, 2020, at 1:30 p.m., confirmed the Memory Garden Courtyard exit, had the above exiting deficiencies.









 Plan of Correction - To be completed: 03/16/2020

Concrete was poured in June 2019 from the point of building egress at each end wing to a public way to assure evacuation could occur safely. Exit signage will be placed on that gate, which is locked from the inside and can be opened by the unit charge nurses and Registered Nurse Managers. An alternative locking mechanism will be explored by the Director of Environmental Services.
The cited gate, padlocked from the outside, is not considered an exit. The gate allows for mowing and snow removal equipment to be brought in for maintenance. The gate will be marked to reflect that it is not an exit.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 document review and interview, the facility failed to maintain sprinkler systems to include one of over ten major sprinkler components.

Findings include:

1. Document review on January 24, 2020, at 8:40 a.m., revealed the facility lacked documentation that an internal pipe (obstruction) exam was performed on the sprinkler system, within the last five years.

Interview with the maintenance supervisor on January 24, 2020, at 8:40 a.m., confirmed the above sprinkler internal pipe exam documentation was not available at the time of the survey




 Plan of Correction - To be completed: 03/16/2020

Absolute Fire Systems provided verification that an internal pipe (obstruction) examination was completed on January 25, 2017. Absolute Fire System's next inspection is already scheduled for January 2022.
NFPA 101 STANDARD Building Services - Other: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.
Building Services - Other
List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services 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: 0500

Based on observation and interview, the facility failed to maintain hot water heaters in one of seven wings.

Findings include:

1. Observation on January 24, 2020, at 11:05 a.m., revealed the ambulance entrance, hot water heater room, had housekeeping carts stored within thirty six inches of the hot water heater.

REFERENCE; NFPA 101-9.2.2, NFPA 99-15.5.2.2, NFPA 31-table 10.6.1.

Interview with the maintenance supervisor on January 24, 2020, at 11:05 a.m., confirmed the above gas hot water heater had combustibles within thirty six inches of the unit.




 Plan of Correction - To be completed: 03/16/2020

The housekeeping carts were relocated upon discovery. Housekeeping staff will be educated to store carts outside the maintenance cage when not in use. The Director of Environmental Services will monitor for compliance.
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




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

Based on document review and interview, the facility failed to maintain fusible-link fire dampers in all locations throughout the building.

Findings include:

1. Document review on January 24, 2020, at 8:50 a.m., revealed the facility lacked documentation to indicate the fusible-link fire dampers were operated and inspected within the last four years (last inspection was documented on December 10, 2015).

Interview with the maintenance supervisor on January 24, 2020, at 8:50 a.m., confirmed the above fusible-link fire damper inspection documentation was not available at the time of the survey.





 Plan of Correction - To be completed: 03/16/2020

All fuseable-link fire dampers will be inspected and recorded on a spread sheet, to validate they are in working order. The Director of Environmental Services will enter the inspection of the fuseable-link fire dampers into TELS electronic work order system, per the scheduled timeframe outline in the regulation to maintain compliance with timely inspection requirements.
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, the facility failed to maintain fire drills during three of four annual quarters.

Findings include:

1. Document review on January 24, 2020, at 8:30 a.m., revealed the facility lacked fire drill documentation for the following quarters/shifts within the last year:
a. first quarter, second shift;
b. third quarter, first shift;
c. fourth quarter, first and third shifts.

Interview with the maintenance supervisor on January 24, 2020, at 8:30 a.m., confirmed the above fire drill documentation was not available at the time of the survey




 Plan of Correction - To be completed: 03/16/2020

A fire drill was held January 21,2020 on the daylight shift. A Quality Assurance Process Improvement committee meeting was held January 29,2020 to complete a fire drill schedule for the rest of the year. The Director of Environmental Services will monitor timely completion of fire drills. The Nursing Home Administrator will review the fire drills monthly for completion.
NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, the facility failed to maintain smoking regulations at one of seven exits.

Findings include:

1. Observation on January 24, 2020, at 11:30 a.m., revealed the dietary porch location had the following smoking deficiencies:
a. dietary porch exit trash container, had discarded cigarette butts inside, with the combustible trash;
b. designated smoking area lacked a self-closing, metal cigarette butt container, for discarded cigarette butts to be emptied;
c. facility is using a plastic plant container as an ashtray.

Interview with the maintenance supervisor on January 24, 2020, at 11:30 a.m., confirmed the above smoking deficiencies.





 Plan of Correction - To be completed: 03/16/2020

A self enclosed metal cigarette butt container and a metal trash can have been added to the smoking pavilion. Staff will be educated on the smoking policy, that includes designated smoking areas, proper disposal of cigarette butts and proper disposal of combustible items in the appropriate trach receptacle.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 observation and interview, the facility failed to maintain essential electrical systems for one of over ten emergency generator functioning components.

Findings include:

1. Observation on January 24, 2020, at 10:15 a.m., revealed the emergency generator servicing this building lacked a remote manual stop station, located outside the room housing the generator, in accordance with NFPA 110, 5.6.5.6.

Interview with the maintenance supervisor on January 24, 2020, at 10:15 a.m., confirmed the emergency generator servicing this building lacked a remote manual stop station.





 Plan of Correction - To be completed: 03/16/2020

A remote emergency stop switch will be installed outside the room where the generator is housed, as well as and alarmed housing to protect the emergency stop station to eliminate the possibility of an accidental trip. Signage will be installed at the emergency stop station and on the protective housing. Photos will be added to the Emergency Preparedness plan.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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, the facility failed to maintain medical gas cylinder storage at one of over one hundred resident bed locations.

Findings include:

1. Observation on January 24, 2020, at 10:45 a.m., revealed an unsecured oxygen cylinder (e-tank) on a walker, in resident room 107.

Interview with the maintenance supervisor on January 24, 2020, at 10:45 a.m., confirmed the above unsecured oxygen cylinder.




 Plan of Correction - To be completed: 03/16/2020

The E tank oxygen cylinder, in resident room 107, was immediately secured. Staff will be educate on the proper storage of oxygen and how to properly secure portable oxygen tanks. The Director of Environmental Services and licensed nursing staff will monitor oxygen tank storage and security daily x 2 weeks, weekly x 2 weeks and monthly x 2 months. Audit results will be reported to the Quality Assurance Process Improvement Committee for further review and recommendation.

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