Pennsylvania Department of Health
 AVALON CARE CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
AVALON CARE CENTER
Inspection Results For:

There are  45 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.
AVALON 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 July 10, 2024, at Avalon Care 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 #194102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 10, 2024, it was determined that Avalon 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 (000), unprotected, wood frame building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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 test and clean carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

Document review on July 10, 2024, at 9:00 a.m., revealed the facility lacked documentation that the carbon monoxide detectors were cleaned, tested, and had batteries replaced within the previous twelve months.

Interview with the administrator and maintenance technician on July 10, 2024, at 9:00 a.m., confirmed the facility lacked the carbon monoxide detector documentation.




 Plan of Correction - To be completed: 09/02/2024

The facility cleaned, tested and replaced batteries on all carbon monoxide detectors. The facility will ensure that moving forward all carbon monoxide detectors are cleaned, tested, and replace batteries at least every 12 months. This documentation has been added to a checklist and a maintenance employee or designee will complete this task. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will include checking to ensure that carbon monoxide detectors are functioning properly. Audits will be completed by the Maintenance Director or designee. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Doors with Self-Closing Devices:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined that the facility failed to maintain doors with self-closing devices for one of over fifteen doors.

Findings include:

Observation on July 10, 2024, at 9:31 a.m., revealed the utility room door near resident room 106 failed to close and latch in the frame.

Interview with the maintenance technician on July 10, 2024, at 9:31 a.m., confirmed the deficiency.






 Plan of Correction - To be completed: 09/02/2024

The cited utility room door has since been fixed and now closes and latches in the frame. Moving forward, the facility will maintain door with self-closing devices. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring to ensure all self-close doors close and latch in the frame. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, the facility failed to inspect and maintain exit and directional signage for three of three building components.

Findings include:

Document review on July 10, 2024, at 11:45 a.m., revealed the facility failed to provide documentation that the exit signs were inspected on a monthly basis during the previous twelve months.

Interview with the administrator and maintenance technician on July 10, 2024, at 11:45 a.m., confirmed the deficiency at the time of the survey.





 Plan of Correction - To be completed: 09/02/2024

The facility inspected all exit signs in the facility. The facility will ensure that moving forward all exit signs are inspected on a monthly basis for the entire 12 month period. This documentation has been added to a checklist and a maintenance employee or designee will complete this task. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include checking to ensure the exit signs are functioning properly. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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, the facility failed to maintain the fire barrier walls to resist passage of smoke, in two of over five hazardous rooms.

Findings include:

Observation on July 10, 2024, at 9:09 a.m., revealed the main floor utility room had multiple unsealed penetrations and unprotected, exposed surfaces that could allow the passage of smoke.

Interview with the maintenance technician on July 10, 2024, at 9:09 a.m. confirmed the unsealed penetrations.







 Plan of Correction - To be completed: 09/02/2024

The facility repaired cited penetrations. The facility will maintain fire barrier walls to resist passage of smoke, as required. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will be done to ensure that any work done on fire barrier walls that the penetration is fire proofed. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review and interview, the facility failed to maintain portable fire extinguisher inspections for two of twelve months.

Findings include:

Document review on July 10, 2024, at 11:30 a.m., revealed the facility lacked documentation for portable fire extinguisher inspections for the months of May and June.

Interview with the maintenance director on July 10, 2024, at 11:30 a.m., confirmed the portable fire extinguisher documentation was unavailable at the time of the survey.




 Plan of Correction - To be completed: 09/02/2024

The facility contacted vendor to complete the missing monthly inspections. The facility will maintain portable fire extinguisher inspections for all 12 months. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will ensure that the monthly inspection tags are completed and attached to the portable fire extinguishers. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Fire Drills: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.
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 meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 10, 2024, at 8:30 a.m., revealed the following shifts lacked unexpected fire drills that varied with time and condition:
A. (8:30 a.m.) First shift, first quarter;
B. (8:30 a.m.) Second shift, second and fourth quarters;
C. (8:30 a.m.) Third shift, second and fourth quarters.

Interview with the administrator and maintenance technician on July 10, 2024, at 8:30 a.m., confirmed the deficiencies.




 Plan of Correction - To be completed: 09/02/2024

The facility held a fire drill and moving forward the facility will meet the fire drill requirements on all shifts. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. This citation and plan of correction will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Electrical Systems - Receptacles:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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, the facility failed to maintain electrical receptacles in two of over thirty rooms.

Findings include:

Observation on July 10, 2024, between 9:16 a.m. and 9:18 a.m., revealed the facility failed to maintain electrical receptacles and ground fault circuit interrupter (GFCI) protection in the following locations:
A. (9:16 a.m.) Main floor staff lounge water cooler was not GFCI-protected;
B. (9:18 a.m.) Main floor staff lounge cabinet receptacle was missing a cover plate:

Interview with the maintenance technician on July 10, 2024, at 9:18 a.m., confirmed the electrical outlet deficiencies.




 Plan of Correction - To be completed: 09/02/2024

The 2 cited receptacles have been corrected. Moving forward the facility will maintain all electrical receptacles throughout the facility. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring to ensure all electrical receptacles are maintained appropriately. 5 random receptacles will be selected for audits. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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, the facility failed to maintain essential electric system maintenance and testing for two of two emergency generators.

Findings include:

Document review on July 10, 2024, at 11:00 a.m., revealed the facility lacked documentation for the following emergency generator testing requirements:
A) Annual fuel analysis report;
B) 3-year, 4-hour load test;
C) Annual 90-minute load bank.

Interview with the administrator and maintenance technician on July 10, 2024, at 11:00 a.m., confirmed the generator documentation was unavailable at the time of the survey.





 Plan of Correction - To be completed: 09/02/2024

The facility scheduled the generator vendor for servicing and to provide the documentation for: the annual fuel analysis report, 3-year 4-hour load test and the annual 90-minute load bank. Moving forward, the facility will ensure that the generator documentation listed previously is in place. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Once generator visit is complete, maintenance employee or designee will audit paperwork to ensure all required documentation is present. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 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 that the facility failed to maintain electrical power cords in two of over thirty rooms.

Findings include:

Observation on July 10, 2024, between 9:03 a.m. and 9:14 a.m., revealed the following power cord deficiencies:
A. (9:03 a.m.) Main floor activities room, had a power strip with a surge protector powering a coffee maker/pot;
B. (9:14 a.m.) Main floor staff break room, had a power strip with a surge protector powering a refrigerator.

Interview with the maintenance technician on July 10, 2024, at 9:14 a.m., confirmed the above power cord deficiencies.







 Plan of Correction - To be completed: 09/02/2024

The facility corrected all cited electrical cords. Moving forward, the facility will maintain electrical power cords. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring all residents rooms and offices to ensure that only appropriate items are plugged into surge protectors. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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 gas equipment storage requirements for two of two storage locations.

Findings include:

Observation on July 10, 2024, at 9:21 a.m., revealed the main floor clean linen room had oxygen cylinders without proper oxygen level labeling or separation based on empty or full cylinders.

An interview with the maintenance technician on July 10, 2024, at 9:21 a.m., confirmed the above deficiency.





 Plan of Correction - To be completed: 09/02/2024

The facility has created designated and segregated full versus empty areas for oxygen cylinders. Moving forward, the facility will maintain gas equipment storage requirements. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring to ensure that the appropriate signage is displayed and adhered to. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #194102
Component 02
Constructed 1962

Based on a Medicare/Medicaid Recertification Survey completed on July 10, 2024, it was determined that Avalon 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 (000), unprotected, wood frame building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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: BUILDING 02 - Component: 02 - Tag: 0100

Based on document review and interview, the facility failed to test and clean carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

Document review on July 10, 2024, at 9:00 a.m., revealed the facility lacked documentation that the carbon monoxide detectors were cleaned, tested, and had batteries replaced within the previous twelve months.

Interview with the administrator and maintenance technician on July 10, 2024, at 9:00 a.m., confirmed the facility lacked the carbon monoxide detector documentation.




 Plan of Correction - To be completed: 09/02/2024

The facility cleaned, tested and replaced batteries on all carbon monoxide detectors. The facility will ensure that moving forward all carbon monoxide detectors are cleaned, tested, and replace batteries at least every 12 months. This documentation has been added to a checklist and a maintenance employee or designee will complete this task. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will include checking to ensure that carbon monoxide detectors are functioning properly. Audits will be completed by the Maintenance Director or designee. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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: BUILDING 02 - Component: 02 - Tag: 0321

Based on observation and interview, the facility failed to maintain the fire barrier walls to resist passage of smoke, in two of over five hazardous rooms.

Findings include:

Observation on July 10, 2024, at 9:56 a.m., revealed the main floor, power room had multiple unsealed penetrations in the rated wall.

Interview with the maintenance technician on July 10, 2024, at 9:56 a.m. confirmed the unsealed penetrations in the rated wall.






 Plan of Correction - To be completed: 09/02/2024

The facility repaired cited penetrations. The facility will maintain fire barrier walls to resist passage of smoke, as required. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will be done to ensure that any work done on fire barrier walls that the penetration is fire proofed. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated
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: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation, document review, and interview, the facility failed to meet sprinkler system testing and maintenance requirements for two of two sprinkler systems.

Findings include:

Document review on July 10, 2024, at 10:30 a.m., revealed the sprinkler system internal pipe and valve inspection was not performed within the last five years. The facility was unable to provide documentation that the internal inspections were completed since February 2018.

Interview with the administrator and maintenance technician on July 10, 2024, at 10:30 a.m., confirmed the internal inspections exceeded the five-year replacement requirement.



Based on observation and interview, it was determined that the facility failed to maintain the sprinkler system for one of over fifty sprinkler heads.

Findings include:

Observation on July 10, 2024, at 10:29 a.m., revealed the med room, near the nurse station had a loose escutcheon plate creating a gap in the ceiling, which can cause a delay in the sprinkler activation.

Interview with the maintenance technician on July 10, 2024, at 10:29 a.m., confirmed the above escutcheon plate was loose.







 Plan of Correction - To be completed: 09/02/2024

The facility contacted vendor to complete the internal pipe and valve inspections. The facility corrected the loose escutcheon plate cited. The facility will ensure that the building meets the sprinkler system testing and maintenance requirements for sprinkler systems. The facility will ensure all escutcheon plates are not loose moving forward. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will ensure that the escutcheon plates are not loose throughout the facility. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. This citation, plan of correction, and audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0355

Based on document review and interview, the facility failed to maintain portable fire extinguisher inspections for two of twelve months.

Findings include:

Document review on July 10, 2024, at 11:30 a.m., revealed the facility lacked documentation for portable fire extinguisher inspections during the months of May and June.

Interview with the maintenance director on July 10, 2024, at 11:30 a.m., confirmed the portable fire extinguisher documentation was unavailable at the time of the survey.




 Plan of Correction - To be completed: 09/02/2024

The facility contacted vendor to complete the missing monthly inspections. The facility will maintain portable fire extinguisher inspections for all 12 months. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will ensure that the monthly inspection tags are completed and attached to the portable fire extinguishers. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Fire Drills: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.
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: BUILDING 02 - Component: 02 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 10, 2024, at 8:30 a.m., revealed the following shifts lacked unexpected fire drills that varied with time and condition:
A. (8:30 a.m.) First shift, first quarter;
B. (8:30 a.m.) Second shift, second and fourth quarters;
C. (8:30 a.m.) Third shift, second and fourth quarters.

Interview with the administrator and maintenance technician on July 10, 2024, at 8:30 a.m., confirmed the deficiencies.




 Plan of Correction - To be completed: 09/02/2024

The facility held a fire drill and moving forward the facility will meet the fire drill requirements on all shifts. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. This citation and plan of correction will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for two of two emergency generators.

Findings include:

Document review on July 10, 2024, at 11:00 a.m., revealed the facility lacked documentation for the following emergency generator testing requirements:
A) Annual fuel analysis report;
B) 3-year, 4-hour load test;
C) Annual 90-minute load bank.

Interview with the administrator and maintenance technician on July 10, 2024, at 11:00 a.m., confirmed the generator documentation was not unavailable at the time of the survey.




 Plan of Correction - To be completed: 09/02/2024

The facility scheduled the generator vendor for servicing and to provide the documentation for: the annual fuel analysis report, 3-year 4-hour load test and the annual 90-minute load bank. Moving forward, the facility will ensure that the generator documentation listed previously is in place. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Once generator visit is complete, maintenance employee or designee will audit paperwork to ensure all required documentation is present. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 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: BUILDING 02 - Component: 02 - Tag: 0920

Based on observation and interview on July 10, 2024, it was determined the facility failed to maintain electrical power cords in one of over ten rooms.

Findings include:

Observation on July 10, 2024, at 10:23 a.m., revealed the administration office had a water cooler plugged into a surge protector.

Interview with the maintenance technician on July 10, 2024, at 10:23 a.m., confirmed the above deficiency.






 Plan of Correction - To be completed: 09/02/2024

The facility corrected all cited electrical cords. Moving forward, the facility will maintain electrical power cords. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring all residents rooms and offices to ensure that only appropriate items are plugged into surge protectors. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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: BUILDING 02 - Component: 02 - Tag: 0923

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in two of two storage locations.

Findings include:

Observation on July 10, 2024, at 10:28 a.m., revealed the main floor clean utility room had oxygen cylinders without oxygen level labeling or separation based on empty or full cylinders.

An interview with the maintenance technician on July 10, 2024, at 10:28 a.m., confirmed the deficiency.






 Plan of Correction - To be completed: 09/02/2024

The facility has created designated and segregated full versus empty areas for oxygen cylinders. Moving forward, the facility will maintain gas equipment storage requirements. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring to ensure that the appropriate signage is displayed and adhered to. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000


Facility ID #194102
Component 03
Construction 2002

Based on a Medicare/Medicaid Recertification Survey completed on July 10, 2024, it was determined that Avalon 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: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.
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: BUILDING 03 - Component: 03 - Tag: 0100

Based on document review and interview, the facility failed to test and clean carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

Document review on July 10, 2024, at 9:00 a.m., revealed the facility lacked documentation that the carbon monoxide detectors were cleaned, tested, and had batteries replaced within the previous twelve months.

Interview with the administrator and maintenance technician on July 10, 2024, at 9:00 a.m., confirmed the facility lacked documentation for carbon monoxide detector inspections.




 Plan of Correction - To be completed: 09/02/2024

The facility cleaned, tested and replaced batteries on all carbon monoxide detectors. The facility will ensure that moving forward all carbon monoxide detectors are cleaned, tested, and replace batteries at least every 12 months. This documentation has been added to a checklist and a maintenance employee or designee will complete this task. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will include checking to ensure that carbon monoxide detectors are functioning properly. Audits will be completed by the Maintenance Director or designee. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0293

Based on document review and interview, the facility failed to inspect and maintain exit and directional signage for three of three building components.

Findings include:

Document review on July 10, 2024, at 11:45 a.m., revealed the facility failed to provide documentation that the exit signs were inspected on a monthly basis during the previous twelve months.

Interview with the administrator and maintenance technician on July 10, 2024, at 11:45 a.m., confirmed the deficiency at the time of the survey.




 Plan of Correction - To be completed: 09/02/2024

The facility inspected all exit signs in the facility. The facility will ensure that moving forward all exit signs are inspected on a monthly basis for the entire 12 month period. This documentation has been added to a checklist and a maintenance employee or designee will complete this task. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include checking to ensure the exit signs are functioning properly. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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: BUILDING 03 - Component: 03 - Tag: 0353

Based on observation, document review, and interview, the facility failed to meet sprinkler system testing and maintenance requirements for two of two sprinkler systems.

Findings include:

Document review on July 10, 2024, at 10:30 a.m., revealed the sprinkler system internal pipe and valve inspection was not performed within the last five years. The facility was unable to provide documentation that the internal inspections were completed since February 2018.

Interview with the administrator and maintenance technician on July 10, 2024, at 10:30 a.m., confirmed the internal inspections exceeded the five-year replacement requirement.




 Plan of Correction - To be completed: 09/02/2024

The facility contacted vendor to complete the internal pipe and valve inspections. The facility will ensure that the building meets the sprinkler system testing and maintenance requirements for sprinkler systems. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. This citation and plan of correction will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0355

Based on document review and interview, the facility failed to maintain portable fire extinguishers for two of twelve months.

Findings include:

Document review on July 10, 2024, at 11:30 a.m., revealed the facility lacked inspection documentation for the portable fire extinguishers for the months of May and June.

Interview with the maintenance director on July 10, 2024, at 11:30 a.m., confirmed the portable fire extinguisher documentation was unavailable at the time of the survey.




 Plan of Correction - To be completed: 09/02/2024

The facility contacted vendor to complete the missing monthly inspections. The facility will maintain portable fire extinguisher inspections for all 12 months. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will ensure that the monthly inspection tags are completed and attached to the portable fire extinguishers. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Fire Drills: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.
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: BUILDING 03 - Component: 03 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 10, 2024, at 8:30 a.m., revealed the following shifts lacked unexpected fire drills that varyied with time and condition:
A. (8:30 a.m.) First shift, first quarter;
B. (8:30 a.m.) Second shift, second and fourth quarters;
C. (8:30 a.m.) Third shift, second and fourth quarters.

Interview with the administrator and maintenance technician on July 10, 2024, at 8:30 a.m., confirmed the deficiencies.




 Plan of Correction - To be completed: 09/02/2024

The facility held a fire drill and moving forward the facility will meet the fire drill requirements on all shifts. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. This citation and plan of correction will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
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: BUILDING 03 - Component: 03 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for two of two emergency generators.

Findings include:

Document review on July 10, 2024, at 11:00 a.m., revealed the facility lacked documentation for the following emergency generator testing requirements:
A) Annual fuel analysis report;
B) 3 year, 4-hour load test;
C) Annual 90-minute load bank.

Interview with the administrator and maintenance technician on July 10, 2024, at 11:00 a.m., confirmed the generator documentation was unavailable at the time of the survey.




 Plan of Correction - To be completed: 09/02/2024

The facility scheduled the generator vendor for servicing and to provide the documentation for: the annual fuel analysis report, 3-year 4-hour load test and the annual 90-minute load bank. Moving forward, the facility will ensure that the generator documentation listed previously is in place. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Once generator visit is complete, maintenance employee or designee will audit paperwork to ensure all required documentation is present. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 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: BUILDING 03 - Component: 03 - Tag: 0920

Based on observation and interview, it was determined that the facility failed to maintain electrical power cords in two of over ten rooms.

Findings include:

Observation on July 10, 2024, between 8:50 a.m. and 9:01 a.m., revealed the following power cord deficiencies:
A. (8:50 a.m.) Main floor dining room had a window air conditioner plugged into a surge protector;
B. (9:01 a.m.) Main floor director of nursing office had a window air conditioner plugged into a surge protector.

Interview with the maintenance technician on July 10, 2024, at 9:01 a.m., confirmed the above deficiencies.






 Plan of Correction - To be completed: 09/02/2024

The facility corrected all cited electrical cords. Moving forward, the facility will maintain electrical power cords. Staff Development Nurse or designee will educate the Maintenance Department on this requirement and the process surrounding the requirement. Audits will be completed by the Maintenance Director or designee. Audits will include monitoring all residents rooms and offices to ensure that only appropriate items are plugged into surge protectors. Audits will be completed weekly for one month, biweekly for one month, and randomly thereafter. Random audits will include at least 5 times/month for 3 months. Audits will be reviewed at the quarterly QAPI Meeting and additional recommendations will be made as indicated.

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