Nursing Investigation Results -

Pennsylvania Department of Health
 VALLEY VIEW HAVEN, INC.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
VALLEY VIEW HAVEN, INC.
Inspection Results For:
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VALLEY VIEW HAVEN, INC. - 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 27, 2022, at Valley View Haven, Inc., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID #220402
Component 01
Main Building (100-300 Wings)

Based on a Medicare/Medicaid Recertification Survey completed on June 27, 2022, it was determined that Valley View Haven, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

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

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

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

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

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation of building construction on June 27, 2022, between 11:00 AM and 1:45 PM, revealed the facility is a two-story, Type III (200), unprotected ordinary structure, which is not permitted in Health Care.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the facility exceeded the maximum allowable story height, for this type of construction.



 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.


The facility will request Division of Safety to conduct an FSES Survey.
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 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain documentation verifying monthly inspections of battery back-up emergency lighting, affecting the entire component.

Findings include:

1. Review of documentation on June 27, 2022, at 10:30 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting had been subjected to a visual inspection between 1/28/22 and 3/17/22.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the lack of documentation verifying monthly battery back-up lighting inspections.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Battery back-up emergency lighting will be checked monthly.

Maintenance or designee will complete random quarterly audits x4 to ensure battery back-up emergency lighting was checked as required with results will be reported to Quality Assurance Committee.
NFPA 101 STANDARD Exit Signage: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.
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 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain documentation, verifying monthly inspections of exit signs, affecting the entire component.

Findings include:

1. Review of documentation on June 27, 2022, at 10:30 AM, revealed the facility failed to provide documentation verifying exit signs had been subjected to a visual inspection between 1/28/22 and 3/17/22.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the lack of documentation verifying monthly exit sign inspections.




 Plan of Correction - To be completed: 08/09/2022


The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Exit signs will have a completed visual inspection monthly.

Maintenance or designee will complete random quarterly audits x4 to ensure exit signs were visually inspected as required with results will be reported to Quality Assurance Committee.
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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free from extraneous weight, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 12:47 PM, revealed the ceiling grid was supported by sprinkler piping in one location, within the Nursing Supervisor's Office.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the ceiling grid was supported by the sprinkler system.



 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.


The grid was removed from the sprinkler pipe and replaced.

Maintenance or designee will complete random quarterly audits x4 to ensure that grids are not being supported by sprinkler pipes as required with results will be reported to Quality Assurance Committee.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments no greater than 22,500 square feet, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, between 11:00 AM and 1:45 PM, revealed the Main Floor smoke compartment was greater than 22,500 square feet.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the smoke compartment was in excess of 22,500 square feet.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

The facility will request Division of Safety to conduct an FSES Survey.
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 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical wiring, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 12:45 PM, revealed approximately 30 feet of non-metallic sheathed electrical cable with a manufacture date of "12/14/2015" installed within the Nursing Supervisor's Office.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the installation of non-metallic sheathed electrical cable after the effective date of the adoption of the 2000 edition of the Life Safety Code.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

The 30 feet of non-metallic sheathed electrical cable will be removed and replaced with approved MC cable.

Maintenance or designee will complete random quarterly audits x4 to ensure that all appropriate cable is used as required with results will be reported to Quality Assurance Committee.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #220402
Component 02
Building 2 (400-500 Wings)

Based on a Medicare/Medicaid Recertification Survey completed on June 27, 2022, it was determined that Valley View Haven, Inc. 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 II (000), unprotected noncombustible structure, which is fully sprinklered.



 Plan of Correction:


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: BUILDING 02 - Component: 02 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain documentation verifying monthly inspections of battery back-up emergency lighting, affecting the entire component.

Findings include:

1. Review of documentation on June 27, 2022, at 10:30 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting had been subjected to a visual inspection, between 1/28/22 and 3/17/22.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the lack of documentation verifying monthly battery back-up lighting inspections.



 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Battery back-up emergency lighting will be checked monthly.

Maintenance or designee will complete random quarterly audits x4 to ensure battery back-up emergency lighting was checked as required with results will be reported to Quality Assurance Committee.

NFPA 101 STANDARD Exit Signage: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.
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 02 - Component: 02 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain documentation, verifying monthly inspections of exit signs, affecting the entire component.

Findings include:

1. Review of documentation on June 27, 2022, at 10:30 AM, revealed the facility failed to provide documentation verifying exit signs had been subjected to a visual inspection, between 1/28/22 and 3/17/22.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the lack of documentation verifying monthly exit sign inspections.




 Plan of Correction - To be completed: 08/09/2022

 The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Exit signs will have a completed visual inspection monthly.

Maintenance or designee will complete random quarterly audits x4 to ensure exit signs were visually inspected as required with results will be reported to Quality Assurance Committee.

NFPA 101 STANDARD Fire Alarm System - Installation:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8




Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0341

Based on observation and interview, it was determined the facility failed to provide adequate smoke detection coverage in all areas, in one of two smoke zones within the component.

Findings include:

1. Observation on June 27, 2022, at 1:10 PM, revealed no smoke detectors were installed in the storage areas by Resident Rooms C325 and C326, which were open to the corridor.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed no smoke detectors were not installed in the areas open to the corridor.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Smoke detector will be installed outside of resident rooms C325 and C326.

Maintenance or designee will complete random quarterly audits x4 to ensure there are adequate smoke detection coverage as required with results will be reported to Quality Assurance Committee.
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: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system, to be free from extraneous weight, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 1:20 PM, revealed two mesh storage containers suspended from sprinkler piping within Resident Room 516.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the containers were suspended from sprinkler piping.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

The mesh storage containers were removed from the sprinkler piping in resident room 516.

Maintenance or designee will complete random quarterly audits x4 to ensure that items are not suspended from sprinkler piping as required with results will be reported to Quality Assurance Committee.
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: BUILDING 02 - Component: 02 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical hardware, in one of two smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 1:10 PM, revealed the two wall-mounted recessed electrical panels in the open storage area, by Resident Room C325, were unlocked and accessible to any unauthorized persons.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the panels were unlocked.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

The electrical panel was immediately locked.

Maintenance or designee will complete random quarterly audits x4 to ensure that all electrical panels are locked as required with results will be reported to Quality Assurance Committee.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen storage locations to be limited to 300 cubic feet of oxygen, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 1:14 PM, revealed 22 "E" size oxygen cylinders, located within the storage alcove by Resident Room C326, which was open to the corridor.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the capacity of oxygen storage, within the alcove, exceeded 300 cubic feet.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Oxygen cylinders were relocated to alternate locations to allow for proper storage. Facility will talk with Oxygen vendor to see if more frequent pick ups can be set up. Staff will be educated on not storing more than 12 E cylinders(300 cubic feet) in the area at one time.

Maintenance or designee will complete random quarterly audits x4 to ensure that Oxygen is storage in the correct capacity as required with results will be reported to Quality Assurance Committee.
Initial comments:Name: NEW ADDITION - Component: 04 - Tag: 0000


Facility ID #220402
Component 04
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on June 27, 2022, it was determined that Valley View Haven, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (III), protected noncombustible structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


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: NEW ADDITION - Component: 04 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain documentation verifying monthly inspections of battery back-up emergency lighting, affecting the entire component.

Findings include:

1. Review of documentation on June 27, 2022, at 10:30 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting had been subjected to a visual inspection, between 1/28/22 and 3/17/22.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the lack of documentation verifying monthly battery back-up lighting inspections.




 Plan of Correction - To be completed: 08/09/2022

 The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Battery back-up emergency lighting will be checked monthly.

Maintenance or designee will complete random quarterly audits x4 to ensure battery back-up emergency lighting was checked as required with results will be reported to Quality Assurance Committee.

NFPA 101 STANDARD Exit Signage: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.
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: NEW ADDITION - Component: 04 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain documentation verifying monthly inspections of exit signs, affecting the entire component.

Findings include:

1. Review of documentation on June 27, 2022, at 10:30 AM, revealed the facility failed to provide documentation verifying exit signs had been subjected to a visual inspection, between 1/28/22 and 3/17/22.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the lack of documentation verifying monthly exit sign inspections.




 Plan of Correction - To be completed: 08/09/2022

 The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Exit signs will have a completed visual inspection monthly.

Maintenance or designee will complete random quarterly audits x4 to ensure exit signs were visually inspected as required with results will be reported to Quality Assurance Committee.

NFPA 101 STANDARD Fire Alarm System - Installation:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8




Observations:
Name: NEW ADDITION - Component: 04 - Tag: 0341

Based on observation and interview, it was determined the facility failed to provide smoke detection in all areas, in two of five smoke zones within the component.

Findings include:

1. Observation on June 27, 2022, at 1:57 PM, revealed no smoke detector was installed in the 1st floor storage areas, by Resident Room 617, which was open to the corridor.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed no smoke detector was installed in this area open to the corridor.

2. Observation on June 27, 2022, at 2:00 PM, revealed no smoke detector was installed in the 1st floor storage areas, by Resident Room 717, which was open to the corridor.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed no smoke detector was installed in this area open to the corridor.




 Plan of Correction - To be completed: 08/09/2022

 The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Smoke detector will be installed outside of resident rooms 617 and 717

Maintenance or designee will complete random quarterly audits x4 to ensure there are adequate smoke detection coverage as required with results will be reported to Quality Assurance Committee.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: NEW ADDITION - Component: 04 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain accessible access to fire extinguishers, in one of four smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 1:35 PM, revealed the fire extinguisher in the 400 Hall Dining Room, on the 1st floor, was blocked by a 4-wheel cart.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the extinguisher was blocked by a cart.



 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Cart was moved away from the fire extinguisher on the 400 hall.
Staff will be educated to not block access to the fire extinguishers.

Maintenance or designee will complete random quarterly audits x4 to ensure that items are not placed in front of fire extinguishers as required with results will be reported to Quality Assurance Committee.
NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: NEW ADDITION - Component: 04 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, and to be unobstructed, in one of five smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 1:45 PM, revealed the double corridor doors to the 1st floor Activities Room failed to close and latch.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the doors did not positively latch.


2. Observation on June 27, 2022, at 1:55 PM, revealed the double corridor doors, to the 2nd floor Activities Room failed to close and latch.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the doors failed to positively latch.


3. Observation on June 27, 2022, at 2:05 PM, revealed the double corridor doors to the 2nd floor Lounge, by the elevators, were both impeded by side chairs.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed both doors were impeded.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Latches will be repaired or replaced to allow for positive latching in the 1st floor Activities Room and 2nd Floor Activities Room. The side chairs that were impeding the doors to the 2nd floor lounge were moved.
Staff will be educated on the process of notifying the maintenance department when a door fails to latch and to ensure that the closure of doors is not impeded.

Maintenance or designee will complete random quarterly audits x4 to ensure all doors have positive latching as required with results will be reported to Quality Assurance Committee.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: NEW ADDITION - Component: 04 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on June 27, 2022, at 2:10 PM, revealed three surge suppressors were suspended from electrical wiring within the basement MDS Office.

Exit interview with the Director of Environmental Services and the Administrator on June 27, 2022, at 2:30 PM, confirmed the suppressors were suspended from electrical wiring.




 Plan of Correction - To be completed: 08/09/2022

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

Surge suppressors will be mounted to the wall in the basement MDS Office.

Maintenance or designee will complete random quarterly audits x4 to ensure that surge suppressors are secured to the appropriate surface as required with results will be reported to Quality Assurance Committee.

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