Nursing Investigation Results -

Pennsylvania Department of Health
PROMEDICA TOTAL REHAB + (PHILADELPHIA)
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PROMEDICA TOTAL REHAB + (PHILADELPHIA)
Inspection Results For:

There are  43 surveys for this facility. Please select a date to view the survey results.

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PROMEDICA TOTAL REHAB + (PHILADELPHIA) - 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 June 22, 2022 at Promedica Total Rehab + (Philadelphia), 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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0000


Facility ID #200402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey conducted on June 22, 2022, it was determined Promedica Total Rehab + (Philadelphia) was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a six-story, Type II (222), fire resistive construction, with a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0100
Based on observation and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility.

Findings Include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of accurate, portable floor plans.



 Plan of Correction - To be completed: 08/23/2022

The facility has accurate, portable floor plans as required, affecting the entire facility.
The plans include the following:
a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

The Maintenance staff will be educated on the Life Safety Code floor plan and everything that needs to be included on it.
An audit of the facility Life Safety Code floor plan will be conducted weekly by the Maintenance Director
The findings of the audit will be brought to Quality Improvement Committee weekly for three weeks and quarterly thereafter

NFPA 101 STANDARD Egress Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain doors with special locking arrangements, affecting two of six levels in the facility.

Findings include:

1. Observation made on June 22, 2022, at 12:20 pm, revealed the delayed egress door to Stair 1 (center stair) on the fifth floor failed to open within 15 seconds.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the door failed to open.


2. Observation made on June 22, 2022, at 1:35 pm, revealed the delayed egress door to Stair 1 (center stair) on the ground floor lacked signage stating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS "

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of signage.



 Plan of Correction - To be completed: 08/21/2022

The facility is correcting doors with special locking arrangements, affecting two of six levels in the facility.
The doors in the following areas will have corrected locking systems to meet Life Safety Code
1. The egress door to Stair 1 (center stair) on the fifth floor will open within 15 seconds.
2. The delayed egress door to Stair 1 (center stair) on the ground floor will have signage stating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS "
Education to Maintenance Staff will be provided to ensure that the center corrects locking system to open within 15 seconds and have signage indicating this by the Adminstrator and Property Management support
An audit of The egress door to Stair 1 on the fifth floor will be conducted to ensure that the door opens within 15 seconds and there is signage stating "Push alarm until alarm sounds door can be opened in 15 seconds" weekly
The findings of the audit will be brought to Quality council monthly for three months and then quarterly thereafter.

NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0281

Based on observation and interview, it was determined the facility failed to illuminate means of egress, affecting one of six levels in the facility.

Findings include:

1. Observation on June 22, 2022, at 1:00 pm, revelaed in Stair 2 on the third floor, the light was burned out.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the stairwell was not illuminated.



 Plan of Correction - To be completed: 08/21/2022

The facility will correct and illuminate means of egress, affecting one of six levels in the facility.
Specifically Stair 2 on the third floor, the light will be replaced.
Education regarding illuminating means of egress will be provided to Maintenance staff by administrator/designee
An audit of the egress on Stair 2 will be conducted wkly to ensure that the light is working and properly illuminating the means of egress.
The findings of the audit will be brought to Quality Improvement committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain emergency lighting, affecting the entire facility.

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility could not produce documentation of monthly 30 second battery backup lighting testing nor annual 90 minute testing.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.




 Plan of Correction - To be completed: 08/21/2022

The facility is maintaining emergency lighting, affecting the entire facility.
1. The facility will conduct a monthly 30 second battery backup lighting testing as well as an annual 90 minute testing.
Education regarding the need to conduct a monthly 30 second battery back up and lighting test as well as an annual 90 minute test will be provided to Maintenance staff by the administrator/designee
An audit of the 30 second battery back up lighting testing as well as an annual 90 minute test will be conducted weekly by the maintenance staff/designee
The findings of the audit will be reviewed in morning meeting monthly for three months then quarterly thereafter


NFPA 101 STANDARD Exit Signage: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.
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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain exit signage, affecting four of the last twelve months.

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility could not produce documentation exit signs had been inspected for the months of March, April, May and June os 2022.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.



 Plan of Correction - To be completed: 08/21/2022

The facility will maintain exit signage monthly
1. The facility will maintain documentation that exit signs are being inspected monthly.
Education regarding the need to maintain exit signage monthly will be provided to the maintenance staff by the Administrator/designee
An audit to ensure documentation is completed monthly on exit signage will be checked weekly by the Maintenance staff/designee
The findings of the audit will be brought to Quality Improvement committee monthly for three months then quarterly thereafter

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain kitchen hood supression systems, affecting 1 of two inspections.

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility could not produce documentation the kitchen hood supression system had been tested within 6 months prior to the February 25, 2022 testing.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.



 Plan of Correction - To be completed: 08/21/2022

The facility will maintain kitchen hood supression systems.
The facility will have the kitchen hood suppression system tested.
Maintenance staff will audit that the test and the documentation for the kitchen suppression system is in place weekly
The findings of the audit will be brought to Quality Improvement committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler systems, affecting one of six levels in the facility.

Findings include:

1. Observation on June 22, 2022, at 1:10 pm, revealed, on the third floor outside Stair 1 (center), excessive debris on the sprinkler.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the excessive debris on the sprinkler.



 Plan of Correction - To be completed: 08/21/2022

The facility will maintain sprinkler systems, specifically:
1. On the third floor outside Stair 1 (center), will have excessive debris removed
Education regarding the maintenance of the sprinkler system and removing debris will be provided to the Maintenance Staff
An audit ensuring that the sprinkler outside of the stair 1 has no debris will be conducted weekly by the Maintenance Staff/designee
The findings of the audit will be brought to Quality Improvement Committee monthly for three months and quarterly thereafter.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the faility did not maintain fire extinguishers, affecting the entire facility.

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility could not produce the service certification for the technician performing the annual fire extinguisher maintenance.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.



 Plan of Correction - To be completed: 08/21/2022

The facility will maintain fire extinguishers, affecting the entire facility. Specifically:
Service for the annual fire extinguisher maintenance for fire extinguishers will be done by certified technicians
Education regarding that annual maintenance and service must be provided by a certified technician will be provided to Maintenance staff/designee
An weekly audit ensuring that fire extinguishers are serviced by certified technician will be conducted by the Maintenance Director/designee
The findings of the audit will be brought to Quality Improvement Committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barriers, affecting one of six levels in the facility.

Findings include:

1. Observations made between 1:40 pm and 1:45 pm, revealed unsealed penetrations and openings above smoke doors in the following locations:

a. 1:40 pm, Ground Floor near Environmental Services, unsealed penetration by data wires;
b. 1:45 pm, Ground Floor across from the elevator, unsealed opening.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the above deficiencies.



 Plan of Correction - To be completed: 08/21/2022

The unsealed penetrations and openings above smoke doors in the following locations will be sealed with a fire resistive product UL approved UL rated through wall fire stop system #W-L-4046:
a. 1:40 pm, Ground Floor near Environmental Services, unsealed penetration by data wires;
b. 1:45 pm, Ground Floor across from the elevator, unsealed opening.
Education regarding the need to ensure that smoke barriers must be kept with sealed penetrations will be provided to Maintenance Staff/designee
An audit of the following locations will be inspected weekly to ensure that there are no penetrations unsealed:
a. 1:40 pm, Ground Floor near Environmental Services, penetration by data wires;
b. 1:45 pm, Ground Floor across from the elevator
The findings of the audit will be brought to Quality Council monthly for three months and quarterly thereafter

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical systems in accordance with NFPA 70, affecting one of six levels in the facility.

Findings include:

1. Observation on June 22, 2022, at 12:45 pm, revealed an unsecured junction box on the fourth floor, above the ceiling at Stair 1 (center).

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the unsecured junction box.



 Plan of Correction - To be completed: 08/21/2022

The facility will maintain electrical systems in accordance with NFPA 70, specifically in the following areas:
1. Junction box on the fourth floor, above the ceiling at Stair 1 (center).
Education regarding that junction boxes need to be kept secure will be provided to Maintenance Staff by Administrator/Designee
An audit of the junction box on the fourth floor above ceiling at Stair 1 will be conducted weekly to ensure that it is secure by Maintenance staff/designee
The findings of the audit will be brought to Quality council monthly for three months and quarterly thereafter

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility faciled to maintain the fire resistance of linen chutes, affecting one of six levels in the facility.

Findings include:

1. Observation on June 22, 2022, at 12:25 pm, revealed the door to the Soiled Linen Chute on the fifth floor lacked self-closer and failed to positively latch.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of lack of of self-closer and failure to positively latch.



 Plan of Correction - To be completed: 08/21/2022

The facility will maintain the fire resistance of linen chutes specifically:
1.the door to the Soiled Linen Chute on the fifth floor lacked self-closer and failed to positively latch.
Education will be provided to maintenance staff on ensuring that the fifth floor self-closer positively latches by the Administrator/Designee
An weekly audit of the fifth floor self- closure positively lathching will be conducted by the Maintenance Staff/designee
The findings of the audit will be reviewed in Quality Improvement Committee monthly for three months and quarterly thereafter


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to inspect fire doors, affecting the entire facility.

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility failed to provide documentation fire doors had been functionally tested within the last 12 months.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.



 Plan of Correction - To be completed: 08/21/2022

The facility will inspect fire doors, affecting the entire facility and keep documentation that fire doors are functional and tested within 12 months
Education was provided to the Maintenance Staff regarding the inspection of fire doors every 12 months and keeping the documentation of the inspection on file
An audit of the fire door inspection documentation will be conducted weekly to ensure that the fire doors inspection documentation is completed and on file
The findings of the documentation will be reviewed in Quality council monthly for three months and quarterly thereafter.

NFPA 101 STANDARD Electrical Systems - Receptacles: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 - 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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0912

Based on documentation review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility.

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.



 Plan of Correction - To be completed: 08/21/2022

The facility will ensure electrical receptacles are tested in patient care rooms and at bed locations, affecting the entire facility specifically:
electrical receptacles testing for
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).
Education on ensuring electrical receptacles are tested in patient care rooms and at bed locations affecting the entire facility will be provided to Maintenance staff by Adminstrator/designee
An audit of electrical receptacles testing for :
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).
will be conducted weekly by the Maintenance staff/designee
The findings of the audit will be reviewed in Quality Improvement Committee monthly for three months and quarterly thereafter

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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0918

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

Findings include:

1. Document review on June 22, 2022, at 8:30 am, revealed the facility could not produce documentation of monthly battery electrolyte testing or conductance testing for the emergency generator for the past 12 months.

Interview at the exit conference with the Maintenance Director and Executive Director on June 22, 2022, at 2:30 pm, confirmed the lack of documentation.




 Plan of Correction - To be completed: 08/21/2022

The facility will maintain and test emergency generator components, affecting the entire facility and maintain documentation of monthly battery electrolyte testing or conductance testing for the emergency generator for the past 12 month
Education regarding testing emergency generator components, affecting the entire facility and maintain documentation of monthly battery electrolyte testing or conductance testing for the emergency generator for the past 12 month will be provided by the Administrator/designee
A weekly audit regarding testing emergency generator components, affecting the entire facility and maintain documentation of monthly battery electrolyte testing or conductance testing for the emergency generator for the past 12 month will be checked by the Maintenance staff/designee
The findings of the audit will be reviewed in Quality Improvement Committee monthly for three months and quarterly thereafter


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