Pennsylvania Department of Health
WALLINGFORD SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 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.


WALLINGFORD SKILLED NURSING AND REHABILITATION 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 June 27, 2024, it was determined that Wallingford Skilled Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

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

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

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

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

.

Observations:
Name: - Component: -- - Tag: 0004
Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.
Findings include:
1. Document review on June 27, 2024, at 8:00 am, revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.
Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 08/06/2024

1.No residents were affected.
2.Emergency Preparedness Plan updated by Administrator on July 4, 2024.
3. Regional Maintenance Director/designee will re-educate responsible staff on updating EPP 4.Maintenance Director/designee will conduct random audit to ensure compliance for 12 months
5.Findings of audits to be reported at QAPI meetings monthly.

403.748(b)(5), 416.54(b)(4), 418.113(b)(3), 441.184(b)(5), 482.15(b)(5), 483.475(b)(5), 483.73(b)(5), 484.102(b)(4), 485.542(b)(5), 485.625(b)(5), 485.68(b)(3), 485.727(b)(3), 485.920(b)(4), 486.360(b)(2), 491.12(b)(3), 494.62(b)(4) STANDARD Policies/Procedures for Medical Documentation:

§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Observations:
Name: - Component: -- - Tag: 0023
Based on documentation review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility.

1. Documentation review on June 27, 2024, at 8:00 am, revealed facility failed to develop Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
Policy and Procedure is current and reviewed at least yearly. Center was in compliance, and was not afforded an opportunity to present to the surveyor.
Regional Maintenance Director/designee will re-educate those responsible in updating the policy and procedure.
Administrator/designee will conduct random audits to ensure compliance.quarterly for 12 months
Finding of audits will be reported to QAPI meetings quarterly x 12 months.

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

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

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

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

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

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

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

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

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

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

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039
Based on document review and interview, it was determined the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 am, revealed the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan within the previous 12 months.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 08/06/2024

No residents were affected.
Table Top exercise was conducted.
Administrator/designee will re-educate Maintenance personnel on policy and regulation.
Administrator/designee will conduct random audits quarterly x 12 months to ensure compliance.
Findings of audits to be reported to QAPI meetings quarterly x 12 months

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

Facility ID# 230102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 27, 2024, it was determined that Wallingford Skilled Nursing and Rehabilitation Center Main Building, 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 two-story, Type III (200), unprotected ordinary construction, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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 01 (MAIN) - Component: 01 - Tag: 0100
Based on observation and interview, it was determined the facility failed to provide accurate, portable floor plans as required; failed to test carbon monoxide alarms, update facility policies, and replace batteries annually in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings Include:

1. Document review on June 27, 2024, at 8:00 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

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed accurate floor plans were not available.

2. Document review on June 27, 2024, at 8:00 am, revealed the facility failed to adhere to the Care Facility Carbon Monoxide Alarms Standards Act in the following ways:

a. The facility failed to ensure that secondary carbon monoxide alarms were tested in accordance with manufacturer's specifications;
b. The facility failed to replace carbon monoxide alarm batteries annually;
c. The facility could not provide a carbon monoxide alarm evacuation plan.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the facility did not adhere to the Care Facility Carbon Monoxide Alarms Standards Act.

Plan of Correction - To be completed: 08/06/2024

1. No residents were adversely affected
2. Floor plans are available, carbon monoxide detectors were inspected,
3. Administrator/designee will re-educate maintenance personnel on mandatory monthly inspections of carbon monoxide detectors.
4. Administrator/designee will conduct monthly audits x3 months to ensure compliance.
5. Findings of audits to be reviewed at QAPI meetings x3 months.

NFPA 101 STANDARD Building Construction Type and Height:

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: BUILDING 01 (MAIN) - Component: 01 - Tag: 0161
Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire building.

Findings include:

1. Observation and document review on June 27, 2024, at 8:00 am, revealed the building was classified as a two story, Type III (200), unprotected ordinary construction, with a basement. The building's story height exceeds the maximum allowance for unprotected ordinary construction.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the building construction and story height.

Plan of Correction - To be completed: 08/20/2024

No residents were adversely affected
Center will be looking to hire Architect to perform a Life Safety Evaluation at the facility
to determine veracity of citation and to determine action step needed to support
corrective action to be into compliance. Investigation and report will take 30 to 45 days,
then depending on outcome and or corrective actions determined additional time will be
needed once determined.

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 01 (MAIN) - Component: 01 - Tag: 0293
Baed on document review and interview, it was determined the facility failed to maintain and inspect exit signs, affecting the entire facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 am, revealed the facility could not provide documentation of monthly exit sign inspection.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
All exit signs have been inspected to ensure compliance.
Regional Maintenance Director/designee will re-educate maintenance personnel on policy & procedure.
All exit signs will be inspected monthly to ensure compliance.
Administrator/designee will complete monthly audits to ensure exit signs have been inspected x 3 months.
Findings of audits to be reported to QAPI meetings x 3 months.

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 01 (MAIN) - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous enclosures, affecting one of three levels in the facility.

Findings include:

1. Observation on June 27, 2024, at 11:23 am, revealed, in the basement. The Salon was being used for storage. The door lacked a self closer.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the door lacked a self closer.

Plan of Correction - To be completed: 08/06/2024

No residents were negatively affected.
A full facility assessment was conducted to ensure that no other locations were being used as improper storage. Room cleared out of all storage items on 6/27/2024.
Maintenance Director/designee to re-educate all staff on policy and procedure of storage areas.
The Maintenance Director/Designee will conduct monthly audits to ensure no areas are used for improper storage.
Findings of audits to be reported to QAPI meeting x3 months.

NFPA 101 STANDARD Cooking Facilities:

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: BUILDING 01 (MAIN) - Component: 01 - Tag: 0324
Based on document review, observation and interview, it ws determined the faiclity failed to maintain kitchen hood suppression systems, affecting the entire facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 am, revealed the following deficiencies:

a. The facility could not provide documentation of a semi-annual kitchen hood suppression system inspection within 6 months of 6/8/2023.
b. Several deficiencies were noted on the inspection dated 6/8/2023. The facility could not provide documentation of their repair.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

2. Observation on June 27, 2924, at 10:59 am, revealed, in the 1st floor kitchen, the kitchen hood suppression system was lacking monthly inspections.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the missing monthly inpsections.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
Suppression system scheduled for inspection on 7/9/24 at 8pm as well as correcting deficiencies found on 6/2023 inspection. Suppression hood inspected by the Maintenance Director and recorded on tag in kitchen. Reports to be kept in Life Safety Binder located in Director of Maintenance office.
Regional Maintenance Director/designee to re-educate maintenance personnel on requirements of kitchen hood suppression system and adding tasks to preventative maintenance system (TELS).
Administrator/designee to conduct monthly audits x 6 months to ensure compliance.
Findings of audits to be reviewed at QAPI meetings x 6 months.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: BUILDING 01 (MAIN) - Component: 01 - Tag: 0342
Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of three levels in the component.

Findings include:

1. Observation on June 27, 2024, at 10:46 am, revelaed, in the 2nd floor stairwell next to resident room 320, the smoke detector ws not securely mounted to the ceiling.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the smoke detector ws not securely mounted.

Plan of Correction - To be completed: 08/06/2024

No resident was adversely affected.
Smoke detector was securely mounted.
Regional Maintenance Director/designee will re-educate maintenance personnel on the importance of securing smoke detectors.
Administrator/designee will conduct random audits x 3 months to ensure smoke detectors are secured.
Findings of audits to be reviewed at QAPI meetings x3 months.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 01 (MAIN) - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 am, revealed the facility could not produce documentation of a 1st quarter sprinkler inspection.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

2. Observation on June 27, 2024, at 10:46 am, revealed, in the 2nd floor stairwell next to resident room 320, a missing ceiling tile.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the missing ceiling tile.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
First quarterly sprinkler inspection was not completed, 2nd Quarter inspection was completed on 5/3/24. . Missing ceiling tile replaced.
Regional Maintenance Director/designee to re-educate maintenance personnel on requirements of quarterly sprinkler inspection and identifying missing ceiling tiles and adding tasks to preventative maintenance system (TELS).
Administrator/designee to conduct random audits x6 months to ensure compliance.
Findings of audits will be reviewed at QAPI meetings x6 months.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 01 (MAIN) - Component: 01 - Tag: 0355
Based on document review, observation and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 am, revealed the facility could not provide the certification of the technician conducting the annual fire extingquisher testing.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of certification.

2. Observation on June 27, 2024, at 10:57 am, revealed, in the 1st floor Kitchen, the K-rated fre extinguisher was blocked by a trash can.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the blocked fire extinguisher.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
Certification of inspector obtained.
Regional Maintenance Director/designee to re-educate maintenance personnel on requirements of annual fire extinguisher inspection.
Administrator/designee to conduct random audits to ensure compliance x 1 year.
Findings of audits to be reviewed at QAPI meetings x year.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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: BUILDING 01 (MAIN) - Component: 01 - Tag: 0371
Based on observation, document review and interview, it was determined the facility failed to maintain the required square footage of smoke compartments, affecting two of five smoke compartments within this building.

Findings include:

1. Observation and document review on June 27, 2024, at 8:00 am, revealed the size of smoke compartments, First and Second Floors, were approximately 24,320 square feet, which exceeds the maximum allowance of 22,500 square feet.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the smoke compartments listed above exceeded the allowable square footage.

Plan of Correction - To be completed: 08/20/2024

No residents were adversely affected.
Center will be looking to hire Architect to perform a Life Safety Evaluation at the facility
to determine veracity of citation and to determine action step needed to support
corrective action to be into compliance. Investigation and report will take 30 to 45 days,
then depending on outcome and corrective actions determine additional time will be
needed once determined.

NFPA 101 STANDARD Utilities - Gas and Electric:

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 01 (MAIN) - Component: 01 - Tag: 0511
Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting the entire component.

Findings include:

1. Observations on June 27, 2024, between 10:41 am and 11:27 am, revealed storage within three feet of the electrical panels in following locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

a. 10:41 am, 2nd floor, RNAC Office;
b. 10:58 am, 1st floor Kitchen;
c. 11:27 am, Basement, electrical panel across from Laundry.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the improper storage in front of the electrical panels.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
All electrical panels have been cleared of equipment, and the area marked with a requirement of 3 foot clearance.
Maintenance Director/designee to re-educate staff on requirements of clearance regarding electrical panels. .
Maintenance Director/designee will conduct random audits x 3 months to ensure compliance.
Findings of audits to be reviewed at QAPI meetings x3 months.

NFPA 101 STANDARD Fire Drills:

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 01 (MAIN) - Component: 01 - Tag: 0712
Based on document review and interview, it was determined the facility failed to properly conduct required fire drills, affecting the whole component.

Findings include:

1. Document review on June 27, 2024, at 8:30 am, revealed the facility could not provide documentation of fire drills for the 1st and 2nd shifts of the 2nd quarter.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
Fire drills conducted for 1st and 2nd shifts.
Regional Maintenance Director/designee to re-educate maintenance personnel on requirements monthly fire drills and provide training.
Administrator/designee to conduct monthly audits x6 months to ensure compliance.
Findings of audits to be reviewed at QAPI meetings x6 months

NFPA 101 STANDARD Electrical Systems - Receptacles:

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: BUILDING 01 (MAIN) - Component: 01 - Tag: 0912
Based on documentation review and interview it was determined the facility failed to ensure that electrical receptacles were tested in patient care rooms and at deep sedation bed locations, within the facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 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).

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed facility could not provide documentation that the receptacles were tested.

Plan of Correction - To be completed: 08/06/2024

No residents were adversely affected.
Receptacles inspected.
Regional Maintenance Director/designee to re-educate maintenance personnel on requirements of receptacle inspections.
Administrator/designee to conduct monthly audits x3 months to ensure compliance.
Findings of audits to be reviewed at QAPI meetings x3 months.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 01 (MAIN) - Component: 01 - Tag: 0918
Based on document review, observation and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

1. Document review on June 27, 2024, at 8:00 am, revealed the facility could not provide documentation of the following tests and inspections:

a. 3 year, 4 hour load test;
b. Annual fuel quality test.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the lack of documentation.

2. Observation on June 27, 2024, at 11:00 am, revealed, on the 1st floor N Nurses Station, the remote generator annuciator was not functioning.

Exit interview with the Administrator and the Maintenance Director on June 27, 2024, at 11:30 am, confirmed the annunciator was not functioning.

Plan of Correction - To be completed: 08/06/2024

1.No residents were adversely affected.
2.Annual testing was conducted on 10/27/2023, 3yr/4hr load was conducted 8/29/2023. Reports to be kept in the Life Safety Binder in the Director of Maintenance office.
3.Regional Maintenance Director/designee to re-educate maintenance personnel on requirements of 3yr/4hour load test and annual fuel quality testing.
4. Administrator/designee to conduct monthly audits x12 months to ensure compliance.
5. Findings of audits to be reviewed at QAPI meetings x12 months.

Initial comments:Name: BUILDING 02 (PT ADDITION) - Component: 02 - Tag: 0000

Facility ID# 230102
Component 02
Physical Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on June 27, 2024, at Wallingford Skilled Nursing and Rehabilitation Center Physical Therapy Addition, it was determined there were no deficiencies identified under the 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 one-story, Type II (111), protected non-combustible construction, which is fully sprinklered.

Plan of Correction:

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