Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-LANCASTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MANORCARE HEALTH SERVICES-LANCASTER
Inspection Results For:
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MANORCARE HEALTH SERVICES-LANCASTER - 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 August 28, 2019, at Manorcare Health Services-Lancaster 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# 231302
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey conducted on August 28, 2019, it was determined that Manorcare Health Services-Lancaster was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected wood frame structure, with a partial basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure exit access and exit corridors were maintained, clear and unobstructed and accessible, on one of two floors within the component.

Findings include:

1. Observation on August 28, 2019, between 11:03 AM and 11:50 AM, revealed items were stored in the corridors, reducing the width to less than 6 feet, at the following locations:

a. 11:03 AM, Robert Fulton Wing, outside Resident Room 9, an electric wheelchair;
b. 11:50 AM, Arcadia Wing, outside Resident Room 115, an unsecured chair;

Interview with the Director of Maintenance on August 28, 2019, at 11:50 AM confirmed items were stored in the corridor.

2. Observation on August 28, 2019, at 12:30 PM revealed two Ecolab wall-mounted dispensers in the receiving corridor, which extended, into the more than 6 inches, below 80 inches.

Interview with the Director of Maintenance on August 28, 2019, at 12:30 PM confirmed the dispensers extended away from the wall more than 6 inches.

Plan of Correction - To be completed: 09/27/2019

1. The Electric Wheelchair outside of Resident Room 9 and the unsecured chair outside of Resident Room 115 were removed by maintenance on August 28, 2019. Both EcoLab wall mounted dispensers were rehung to the correct height on August 13, 2019.
2. Corrective Action occurred immediately to insure compliance with clear and unobstructed means of egress. Education of staff will be completed by September 27, 2019.
3. Nursing staff will be educated on the need to maintain means of egress. Means of egress is continuously maintained free of all obstructions to full use in case of emergencies.
4. Director of Maintenance/Designee will complete an audit of two nursing units for unobstructed egress x four weeks. Then he will continue to complete an audit of one nursing unit monthly x 4. All findings will be reviewed at QAPI to insure continued compliance.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors to self-close, positively latch, to have a fire rated label, and to be within the allowed gap margins, on two of two floors within the component.

Findings include:

1. Observation on August 28, 2019, at 10:40 PM revealed the basement stairtower door lacked a fire-rated label, had no closure and did not have latching hardware.

Interview with the Director of Maintenance on August 28, 2019, at 10:40 PM confirmed the stairtower door did not self-close and positively latch.

2. Observation on August 28, 2019, at 10:42 PM revealed the 1st floor stairtower door lacked a fire-rated label and had a undercut, greater than 3/4 inch.

Interview with the Director of Maintenance on August 28, 2019, at 10:42 PM confirmed stairtower door did not have a rating plate, and exceeded the allowed gap margins.

Plan of Correction - To be completed: 10/20/2019

1. For the basement stair tower a new fire rated door and hardware has been ordered. The door does have a fire rated label on it, on top also a new UL approved door sweep will be installed.
2. The new fire rated door and hardware will be installed by October 10, 2019. The UL approved door sweep will be installed by October 20, 2019.
3. Maintenance Director will complete a full door audit of doors in the facility to identify any other doors that do not meet code.
4. All doors that were identified during survey will be audited for compliance with regulation once a week for four weeks, then once per month for three months. Audits will be reviewed in QAPI monthly.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

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.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to maintain exit access to be unobstructed and readily accessible at all times, affecting four of seven smoke compartments within the component.

Findings include:

1. Observation on August 28, 2019, at 10:00 AM at revealed the basement had only one acceptable means of egress.

Interview with the Director of Maintenance on August 28, 2019, at 10:00 AM confirmed the basement lacked two acceptable means of egress.

2. Observation on August 28, 2019, at 12:20 PM revealed the Buchanan Wing egress was through the Dining Room.

Interview with the Director of Maintenance on August 28, 2019, at 12:20 PM confirmed the exit location was in an intervening room.

Plan of Correction - To be completed: 10/20/2019

1. The facility respectfully requests that the Department of Health conduct the Fire Safety Evaluation System for the basement and Buchanan Wing egress.
2. Corrective Action date to be determined by the Department of Health.
3. The facility will follow what is determined by what is determined by the evaluation.
4. The evaluation will be incorporated in the Fire Safety response procedures as applicable.

NFPA 101 STANDARD Discharge from Exits:

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain discharge from exits, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on August 28, 2019, at 11:56 AM revealed the exterior exit door, by Resident Room 117, required greater than 30 pounds of force to set it motion, from the frame.

Interview with the Director of Maintenance on August 28, 2019, at 11:56 AM confirmed the door was tight in the frame and resisted opening, except by use of excessive force.

Plan of Correction - To be completed: 09/06/2019

1. The exterior door on the Arcadia Unit near room 117 was adjusted to close and latch in frame with less than 30 pounds of force.
2. Corrective Action - the door is functionally operational as of September 6, 2019.
3. Maintenance Director will complete a full door audit of doors in the facility to identify any other doors that do not meet code.
4. All doors that were identified during survey will be audited for compliance with regulation once a week for four weeks, then once per month for twelve months. Audits will be reviewed in QAPI monthly.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within allowed gap margins, and in good repair, on two of two floors within the component.

Findings include:

1. Observation on August 28, 2019, between 10:30 AM and 10:50 AM, revealed hazardous area doors exceeded the allowed gap margins, and were missing screws, at the following locations:

a. 10:30 AM, basement, Mechanical Room door had gaps, greater than 3/16 inch, and screws missing from the hinges;
b. 10:45 AM, 1st floor, Biohazard Room had a gap, greater than 3/16 inch, along the top;
c. 10:50 AM, 1st floor, Housekeeping Supplies had gaps, greater than 3/16 inch.

Interview with the Director of Maintenance on August 28, 2019, at 10:50 AM confirmed hazardous area doors exceeded the allowed gap margins, and were missing screws.

Plan of Correction - To be completed: 09/30/2019

1. The mechanical room door, biohazard room door and the housekeeping supplies doors will be adjusted and made to be smoke tight. Screws will be installed in the mechanical room door by maintenance.
2. The mechanical room door, biohazard room door and the housekeeping supplies doors will be adjusted and made to be smoke tight by September 30, 2019.
3. Maintenance Director will complete a full door audit of doors in the facility to identify any other doors that do not meet code.
4. All doors that were identified during survey will be audited for compliance with regulation once a week for four weeks, then Quarterly for 4 quarters. Audits will be reviewed in QAPI weekly for four weeks and then quarterly for four quarters.

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: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide the owner's quick checks on all extinguishers, affecting one of seven smoke compartments within the component.

Findings include:

1. Review of documentation on August 28, 2019, at 12:01 PM revealed the facility lacked documentation verifying the portable fire extinguisher located in the Fantasy Island Courtyard, had been inspected, between March 14, 2019 and May 22, 2019.

Interview with the Director of Maintenance on August 28, 2019, at 12:01 PM confirmed the facility could not verify the owner's quick checks had been performed.

Plan of Correction - To be completed: 09/10/2019

1. The portable fire extinguisher located in the Fantasy Island Courtyard was replaced and a new log was begun for this extinguisher.
2. Corrective action was completed on September 10, 2019.
3. The Maintenance Director will review fire extinguisher logs monthly.
4. The Assistant Nursing Home Administrator will audit the fire extinguisher logs for compliance monthly for 4 months and will initial them to demonstrate compliance.

NFPA 101 STANDARD Corridor - Doors:

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: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, on one of two floors within the component.

Findings include:

1. Observation on August 28, 2019, between 10:55 AM and 12:40 PM, revealed corridor doors failed to positively latch, at the following locations:

a. 10:55 AM, Activity Room door, off the Lounge by the Entrance, was hitting the frame and not closing and latching;
b. 11:00 AM, Office, by Resident Room 5, was hitting the frame;
c. 11:05 AM, Resident Room 18 was hitting the frame;
d. 11:07 AM, Resident Room 20 was hitting the frame;
e. 11:10 AM, Resident Room 25;
f. 11:15 AM, Resident Room 45 was hitting the frame;
g. 11:42 AM, Resident Room 104;
h. 12:00 PM, Resident Room 60 was hitting the frame;
i. 12:10 PM, Resident Room 79;
j. 12:15 PM, Resident Room 87, was hitting the frame;
k. 12:28 PM, Housekeeping/Laundry Office was hitting the frame;
l. 12:32 PM, Kitchen door, by the Kitchen Office;
m. 12:40 PM, Kitchen door to Dining Room.

Interview with the Director of Maintenance on August 28, 2019, at 12:40 PM confirmed corridor door failed to positively latch.

2. Observation on August 28, 2019, between 11:55 AM and 12:40 PM, revealed holes in the corridor doors, at the following locations:

a. 11:55 AM, Storage Room, by Resident Room 115, had holes, from old hardware;
b. 12:40 PM, Kitchen door to Dining Room, which is labeled, had an unsealed hole from old hardware.

Interview with the Director of Maintenance on August 28, 2019, at 12:40 PM confirmed the doors had unsealed holes.

3. Observation on August 28, 2019, at 12:20 PM revealed the Dining/Lounge door is a fire-rated door, with a gap greater 3/16 of an inch, and is damaged; by Resident Room 89.

Interview with the Director of Maintenance on August 28, 2019, at 12:20 PM confirmed the door exceeds the allowed gap margins.

Plan of Correction - To be completed: 10/10/2019

1. The doors will be adjusted to close and latch in frames (A,B,C,D,E,F,G,I,J,K,L,M). The storage room and kitchen doors will be repaired to be made smoke tight. New door and frame has been ordered; and the door will be adjusted to close and latch into frame (H) until the new door/frame arrive.
2. The doors with gaps or not properly latching will be adjust will be corrected by maintenance by September 30, 2019. The storage room door and the kitchen door will be repaired by September 30, 2019. The door identified in section H will be adjusted to latch appropriately by September 30, 2019 but will be replaced by October 10, 2019.
3. Maintenance Director will complete a full door audit of doors in the facility to identify any other doors that do not meet code.
4. All doors that were identified during survey will be audited for compliance with regulation once a week for four weeks, then once per month for twelve months. Audits will be reviewed in QAPI monthly.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, affecting three of seven smoke compartments within the component.

Findings include:

1. Observation on August 28, 2019, at 11:11 AM revealed the access panel located in the Attic smoke barrier wall, near Resident Room 14, was open and not latched within the frame.

Interview with the Director of Maintenance on August 28, 2019, at 11:11 AM confirmed the access panel was open.

2. Observation on August 28, 2019, at 11:27 AM revealed a penetration of the Attic smoke barrier wall, around blue and white wires, close to the access panel.

Interview with the Director of Maintenance on August 28, 2019, at 11:27 AM confirmed the unprotected penetration.

Plan of Correction - To be completed: 09/13/2019

1. The access panel located in the attic smoke barrier wall was closed and latched immediately during survey. The penetration
2. Corrective action was completed on September 13, 2019.
3. Director completed a visual observation of the area and no further gaps or penetrations were identified.
Penetration was repaired using an approved through penetration fire stop system.
The rating of the smoke barrier wall will be maintained.
4. The Director of Maintenance will complete an inspection following any new installation/construction that occurs in the building to insure that smoke barrier walls remain intact with proper closures and no improperly sealed penetrations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain thesmoke barrier doors to be wtihin the allowed gap margins, and to be smoke resistant, affecting four of seven smoke compartments within the component.

Findings include:

1. Observation on August 28, 2019, at 10:47 AM revealed the smoke barrier door by the basement stairs, with fire-rated labels, had gaps greater than 1/8 inch.

Interview with the Director of Maintenance on August 28, 2019, at 10:47 AM confirmed the smoke barrier doors exceeded the allowed gap margins.

2. Observation on August 28, 2019, at 12:25 PM revealed the smoke barrier door, by Resident Room 67, with fire-rated labels, had unsealed holes, which were puttied improperly and the door is damaged.

Interview with the Director of Maintenance on August 28, 2019, at 12:25 PM confirmed the smoke barrier door was not smoke resistant.

Plan of Correction - To be completed: 09/30/2019

1. The smoke barrier door by the basement stairs was adjusted and made to be smoke tight. The putty on the smoke barrier door by resident room 67 will be removed and new bolts will be installed. The door will be repaired.
2. Corrective action will be achieved by September 30, 2019.
3. Maintenance Director will complete a full door audit of doors in the facility to identify any other doors that do not meet code.
4. All doors that were identified during survey will be audited for compliance with regulation once a week for four weeks, then quarterly for one year. Audits will be reviewed in QAPI monthly for one month and then quarterly for one year.

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: MAIN BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical junction boxes to be covered, and provide fire protected wiring, affecting three of seven smoke compartments within the component.

Findings include:

1. Observation on August 28, 2019, at 11:19 AM revealed an electrical junction box lacked a cover plate, above the Nurses' Station, as seen from the Central Bath.

Interview with the Director of Maintenance on August 28, 2019, at 11:19 AM confirmed the junction box lacked a cover plate.

2. Observation on August 28, 2019, at 11:38 AM revealed approximately 40 feet of non-metallic sheathed electrical cable, with a manufacture date of 6/3/2004, in use between two electrical outlets, above the corridor ceiling by the Boiler Room.

Interview with the Director of Maintenance on August 28, 2019, at 11:38 AM confirmed the use of non-metallic sheathed electrical cable.

3. Observation on August 28, 2019, at 12:24 PM revealed approximately 40 feet of non-metallic sheathed electrical cable, with a manufacture date of 1/13/09, in use above Resident Room 67.

Interview with the Director of Maintenance on August 28, 2019, at 12:24 PM confirmed the use of non-metallic sheathed electrical cable.

Plan of Correction - To be completed: 10/10/2019

1. The missing junction box cover plate located above the nursing station was installed on August 28, 2019. The non-metallic cable will be removed and replaced with Hospital Grade MC cable.
2. Corrective Action will be completed by October 10, 2019.
3. The Maintenance Director completed an audit on August 29, 2019 where he found and corrected some additional missing cover plate issues.
4. The Maintenance Director will complete an inspection following any new installation/construction that occurs in the building to insure that electrical wiring and equipment complies with NFPA 70, National Electric Code.

NFPA 101 STANDARD Soiled Linen and Trash Containers:

Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0754

Based on observation and interview, it was determined the facility failed to store soiled linen containers in a hazardous area, on one of two floors within the component.

Findings include:

1. Observation on August 28, 2019, at 11:45 AM revealed two soiled-linen containers, exceeding 32 gallons, were being stored in the Arcadia Wing Spa.

Interview with the Director of Maintenance on August 28, 2019, at 11:45 AM confirmed the containers were stored outside of a protected hazardous storage area.

Plan of Correction - To be completed: 09/20/2019

1. The two soiled linen containers were separated and returned to the laundry for processing on August 28, 2019.
2. Corrective action will be completed by September 20, 2019.
3. Housekeeping staff will be educated on the regulation: Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area.
4. Housekeeping Supervisor will complete an audit to insure that two soiled linen containers are not stored together. Audits will be completed on two halls once per week for four weeks and then monthly for three months. These audits will be reviewed at the monthly QAPI meeting.

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: MAIN BUILDING - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide an emergency stop outside the generator enclosure, which serves the entire component.

Findings include:

1. Observations on August 28, 2019, at 12:05 PM revealed the required remote manual stop station for the generator had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on August 28, 2019, at 12:05 PM confirmed the switch had not been installed.

Plan of Correction - To be completed: 10/10/2019

1. Director of Maintenance has made plans with the appropriate vendor to correct this deficiency in a timely manner.
2. The emergency stop button will be installed by October 10, 2019.
3. Once installed there will be no systemic change necessary to insurance recurrence.
4. The emergency stop will be tested in accordance with regulatory guidance NFPA code 111.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of electrical devices, on one of two floors within the component.

Findings include:

1. Observation on August 28, 2019, at 11:20 AM revealed a refrigerator, a coffee pot, a charger and radio were plugged into a surge protector, in the MDS Office.

Interview with the Director of Maintenance on August 28, 2019, at 11:20 AM confirmed the unauthorized use of the surge protector.

.

Plan of Correction - To be completed: 09/10/2019

1. On September 10, 2019 the surge protector in use at the MDS office was removed.
2. Corrective action occurred on September 10, 2019.
3. The RNAC's (Registered Nurse Assessment Coordinators who complete MDS data) were educated by the Administrator at afternoon meeting regarding the use of surge protectors/power cords/strips in a patient care vicinity.
4. Director of Maintenance will do an audit of the MDS office to insure proper that no surge protectors, power cords and extension cords are in use. This audit will occur once per month for three months and the audits will be reviewed at QAPI.

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