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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ABBEYVILLE 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 February 19, 2025, at Abbeyville Skilled Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #231302
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on February 19, 2025, it was determined that Abbeyville Skilled Nursing and Rehabilitation Center, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

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

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation on February 19, 2025, at 10:28 AM, revealed the facility failed to notify the authority having jurisdiction of the loss of functionality of the emergency generator, and the use of a temporary generator from approximately 12/5/24 - 1/6/25.

Interview with the Maintenance Director on February 19, 2025, at 10:28 AM, confirmed the lack of documentation verifying the authority having jurisdiction was notified of the loss of functionality of the emergency generator.

Plan of Correction - To be completed: 04/04/2025

1.NHA reported event to the Department of Health for non compliance and interruption in back up generator use for continued safe operation of the facility.
2. Maintenance Director and Maintenance Assistant will be educated on Tag K0100 responsibility of the licensee and the timeline of reporting to the Department of Health.
3.Maintenance will be audited weekly for six weeks to ensure compliance.
4.Results of audit reported to QA committee

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 maintain unobstructed access to emergency egress, affecting three of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:14 AM, revealed the door to the Zone 2 Service Hall Laundry Room was equipped with a key lock, operable solely from the outside of the room.

Interview with the Maintenance Director on February 19, 2025, at 11:14 AM, confirmed the Laundry Room could be locked against emergency egress.

2. Observation on February 19, 2025, between 11:23 AM and 11:31 AM, revealed exterior emergency exit doors were locked against emergency egress with zip ties, in the following locations:

a) 11:23 AM, Zone 4, across from the Central Bath;
b) 11:31 AM, Zone 4, across from the vending machines, near the Roosevelt Wing entrance.

Interview with the Maintenance Director on February 19, 2025, at 11:31 AM, confirmed the exit doors were locked against emergency egress.

3. Observation on February 19, 2025, at 11:40 AM, revealed an "EXIT" sign located on a padlocked gate within the fence of the Roosevelt Courtyard. This gate is not within an egress path consisting of a hardened surface to a public way.

Interview with the Maintenance Director on February 19, 2025, at 11:40 AM, confirmed the gate was marked as an exit, was padlocked against egress, and was not in an egress pathway consisting of a hardened surface to a public way.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance removed lock on Laundry room door on 2/19/25
2. Maintenance to repaired hole with metal plateby 3/8/2025 on the laundry room door. Vendor to repair doors on 3/5/2025. Maintenance to remove exit sign from exterior gate by Roosevelt unit.
2. Maintenance Director and Maintenance Assistant will be educated on Tag K0211 Means of Egress.
3.Maintenance will audit all Emergency exit doors twice a month to ensure they are free and clear of obstruction for all 12 months.
4.Results of audit reported to QA committee

NFPA 101 STANDARD Number of Exits - Story and Compartment:

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.

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 two of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 10:50 AM, revealed the basement had only one acceptable means of egress.

Interview with the Maintenance Director on February 19, 2025, at 10:50 AM, confirmed the basement lacked two acceptable means of egress.

2. Observation on February 19, 2025, at 1:00 PM, revealed the Buchanan Wing egress was through the Dining Room.

Interview with the Maintenance Director on February 19, 2025, at 1:00 PM, confirmed the exit location was in an intervening room.

Plan of Correction - To be completed: 04/04/2025

1. The facility respectfully requests that the Department of Health conduct the Fire Safety Evaluation system for the basement and Buchanan Wing egress.

NFPA 101 STANDARD Emergency Lighting:

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 provide documentation verifying battery back-up emergency lighting fixtures had been inspected on a monthly basis, during the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on February 19, 2025, at 10:11 AM, revealed the facility lacked documentation verifying battery back-up emergency lighting fixtures had been inspected since April 30, 2024.

Interview with the Director of Maintenance on February 19, 2025, at 10:11 AM, confirmed the lack of documentation verifying battery back-up emergency lighting fixtures had been inspected since April 30, 2024.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance inspected emergency back up lights and found them to be operational.
2. Maintenance will continue to use audit tool in TELS system, then print completion and keep in binder to be readily available. the annual 90 minute battery back up lighting test date will be completed 3/6/25.
2. Maintenance Director and Maintenance Assistant will be educated on Tag K0291 and keeping documentation readily available.
3.Maintenance will audit all Emergency back up lights weekly for four weeks then monthly thereafter.
4.Results of audit reported to QA committee

NFPA 101 STANDARD Exit Signage:

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 provide documentation verifying exit signs had been visually inspected on a monthly basis, during the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on February 19, 2025, at 9:52 AM, revealed the facility lacked documentation verifying monthly visual inspections of exit signs had occurred within the previous twelve months, except during the months of February, 2024, and September, 2024.

Interview with the Maintenance Director on February 19, 2025, at 9:52 AM, confirmed the lack of documentation verifying monthly visual exit sign inspections had occurred during the previous twelve months.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance inspected exit signs and found them to be operational.
2. Maintenance will continue to use audit tool in TELS system, then print completion and keep in binder to be readily available.
2. Maintenance Director and Maintenance Assistant will be educated on Tag K0293 and keeping documentation readily available.
3.Maintenance will audit all Exit Signs weekly for six weeks; then monthly thereafter.
4.Results of audit reported to QA committee

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 the smoke resistance of hazardous area enclosures, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:53 AM, revealed the Zone 5 door to the Biohazard Room, next to Resident Room 107, failed to positively latch within the door frame.

Interview with the Maintenance Director on February 19, 2025, at 11:53 AM, confirmed the door did not latch within the frame.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance adjusted Biohazard room door near room 107 to have a positive latch.
2. Maintenance will continue to use audit tool in TELS system, then print completion and keep in binder to be readily available.
2. All staff will be educated on Tag K0321 Hazardous Areas- Enclosure reporting into TELS system and keeping documentation readily available.
3.Maintenance will audit all hazard doors monthly.
4.Results of audit reported to QA committee

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: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to provide documentation verifying owner's quick checks had been performed on the Kitchen Fire Suppression System during the previous twelve months, affecting one of seven smoke compartments within the component.

Findings include:

1. Review of documentation on February 19, 2025, at 9:45 AM, revealed the facility failed to provide documentation verifying monthly owner's quick checks of the Kitchen Fire Suppression System had been performed during the previous twelve months.

Interview with the Maintenance Director on February 19, 2025, at 9:45 AM, confirmed the lack of documentation verifying monthly owner's quick checks of the Kitchen Fire Suppression System had been performed during the previous twelve months.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance and Vendor inspected fire suppression system.
2. Maintenance will be educated on K0324 Kitchen Facilities -Fire suppression system and keeping documentation readily available.
3.Maintenance will audit the fire suppression system weekly; then monthly thereafter.
4.Results of audit reported to QA committee

NFPA 101 STANDARD Fire Alarm System - Out of Service:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0346

Based on document review and interview, it was determined the facility failed to provide documentation verifying the authority having jurisdiction was notified of the loss of the functionality of the fire alarm system, and the occurrence of a fire watch during the period the facility was unprotected, affecting the entire component.

Findings include:

1. Review of documentation on February 19, 2025, at 10:44 AM, revealed the following noted on the sprinkler inspection dated 12/4/24 "Fire Alarm Panel was out of service upon arrival and departure. Facility has fire watch active and is aware of the issue." The facility failed to notify the authority having jurisdiction of the loss of the functionality of the fire alarm panel, and to provide documentation verifying a fire watch was conducted during this time.

Interview with the Maintenance Director on February 19, 2025, at 10:44 AM, confirmed the lack of documentation verifying the authority having jurisdiction was notified of the loss of the functionality of the fire alarm panel and that a fire watch was conducted during this time.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance located missing fire watch and put in binder.
2. Maintenance will be educated on K0326 Fire alarm system- out of service and keeping documentation readily available.
3. Facility is no longer on fire watch.Maintenance will audit the fire alarm system daily for four weeks; then weekly. Fire Watch audits will have a final audit to confirm the watch is over and all documentation has been filed in the life safety book. The administrator will submit an event in the Department of Health system of events that affect infrastructure systems such as fire alarm and sprinkler status.
4.Results of audit reported to QA committee

NFPA 101 STANDARD Sprinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to install sprinkler heads at a minimum spacing from each other, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:06 AM, revealed the two sprinkler heads protecting the Zone 2 Service Entrance Hallway were not spaced at least six feet apart from each other.

Interview with the Maintenance Director on February 19, 2025, at 11:06 AM, confirmed the sprinkler heads were not a minimum of six feet apart from each other.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance contacted vendor to come out and move sprinkler to meet compliance; will be resolved on 3/17/2025.
2. Maintenance will be educated on K0351 Sprinkler system- installation.
3.Maintenance will audit the installation of all sprinklers; then annually thereafter.
4.Results of audit reported to QA committee

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: MAIN BUILDING - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain audible sprinkelr notification devices, affecting the entire component.

Findings include:

1. Review of documentation on February 19, 2025, at 9:30 AM, revealed the most recent sprinkler inspection (dated 12/4/24) indicated the "water motor gong did not ring on riser #1." The facility failed to provide documentation verifying any corrective action had been taken to correct the deficiency.

Interview with the Maintenance Director on February 19, 2025, at 9:30 AM, confirmed the fire alarm inspection deficiency and the failure to provide documentation verifying corrective action.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance will have vendor replace water motor gong.
2.Maintenance will be educated on Tag K0353 Sprinkler inspection.
3.NHA will audit sprinkler inspection and any findings along with binder where documentation needs to be maintained; then quarterly thereafter.
4.Results of audit reported to QA committee

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:10 AM, revealed three unprotected penetrations of the corridor wall, between Zone 1 Resident Rooms 83 and 85.

Interview with the Maintenance Director on February 19, 2025, at 11:10 AM, confirmed the unprotected penetrations of the corridor wall.

2. Observation on February 19, 2025, at 11:25 AM, revealed an unprotected penetration of the corridor wall, beside Zone 4 Resident Room 15.

Interview with the Maintenance Director on February 19, 2025, at 11:25 AM, confirmed the unprotected penetration of the corridor wall.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance repaired unprotected penetrations near rooms 83, 85, and 15.
2. Maintenance and staff will be educated on K0362 Unprotected penetrations.
3.When facility has a project that impacts the corridor walls, the maintenance director and/or Administrator must conduct an audit and sign off on the work order that all holes have been repaired with the appropriate material for that wall.
4.Results of audit reported to QA committee

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 maintain the unobstructed closing and positive latching of corridor doors, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:36 AM, revealed the Zone 5 door to Resident Room 169 was obstructed from closing by a clothes hanger hung from the doorknob.

Interview with the Maintenance Director on February 19, 2025, at 11:36 AM, confirmed the obstructed corridor door.

2. Observation on February 19, 2025, at 11:49 AM, revealed the Zone 5 door to the Folding Room failed to positively latch within the door frame.

Interview with the Maintenance Director on February 19, 2025, at 11:49 AM, confirmed the door did not latch within the frame.

3. Observation on February 19, 2025, at 12:10 PM, revealed the Zone 3 door to the Janitor's Closet, across from Resident Room 5, failed to positively latch within the door frame.

Interview with the Maintenance Director on February 19, 2025, at 12:10 PM, confirmed the door did not latch within the frame.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance removed hanger from obstructing door closing. Maintenance to adjust doors to comply with positive latch.
2. Maintenance and staff will be educated on K0363 Corridor Doors.
3.Maintenance will audit all corridor doors to ensure positive latch; then will do random doors monthly.
4.Results of audit reported to QA committee

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 the unobstructed closing of smoke barrier doors, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:25 AM, revealed both leaves of the cross-corridor smoke barrier doors separating Zone 2 and Zone 4, by Resident Room 21, were held open by metal screws placed beneath the open doors.

Interview with the Maintenance Director on February 19, 2025, at 11:25 AM, confirmed the smoke barrier doors were held open by unauthorized means and would not close upon activation of the fire alarm.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance removed screws to ensure cross-corridor smoke barrier closes. Maintenance to have vendor repair door.
2. Maintenance will be educated on K0374 Smoke barrier Doors.
3.Maintenance will audit all smoke barrier doors to ensure unobstructed closing; then monthly thereafter.
4.Results of audit reported to QA committee

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: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to provide documentation verifying fire drills had been conducted quarterly, on each shift, during the previous twelve months, affecting the entire component.

Findings include:

1. Observation on February 19, 2025, at 9:00 AM, revealed the facility lacked documentation verifying fire drills had been conducted since 2nd shift of March, 2024.

Interview with the Director of Maintenance on February 19, 2025, at 9:00 AM, confirmed the lack of documentation verifying fire drills had been conducted since March, 2024.

Plan of Correction - To be completed: 04/04/2025

1.Maintenance found missing documentation of fire drills and sent to surveyor.
2. Maintenance will be educated on K0712 Fire drills and having documentation readily available.
3.NHA will audit fire drills weekly for four weeks; then monthly thereafter.
4.Results of audit reported to QA committee

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 receptacle multipliers, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on February 19, 2025, at 11:00 AM, revealed the use of a three-to-one receptacle multiplier within the Zone 7 basement Storage Room.

Interview with the Maintenance Director on February 19, 2025, at 11:00 AM, confirmed the use of a receptacle multiplier.

2. Observation on February 19, 2025, at 11:45 AM, revealed the use of a three-to-one receptacle multiplier within the Zone 5 Laundry Room, behind the washing machines.

Interview with the Maintenance Director on February 19, 2025, at 11:45 AM, confirmed the use of a receptacle multiplier.

Plan of Correction - To be completed: 04/04/2025

1.Vendor to replace receptacle to a 4 switch receptacle on 3/5/2025.
2. Maintenance will be educated on K0920 Power cords and Extensions
3.Maintenance will audit all outlets to make sure they are in compliance; then random outlets monthly. Audits for this will be done at higher frequency during peak decorating times, and when new equipment is being installed.
4.Results of audit reported to QA committee

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