Pennsylvania Department of Health
RICHFIELD HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RICHFIELD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  46 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.
RICHFIELD HEALTHCARE 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 March 19, 2024, at Richfield Healthcare 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: EAST BUILDING - Component: 01 - Tag: 0000


Facility ID #260202
Component 01
East Building

Based on a Medicare/Medicaid Recertification Survey completed on March 19, 2024, it was determined that Richfield Healthcare 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 two-story, Type V (111), protected wood frame structure, without a 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: EAST BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access to be readily accessible, for one of three exits within the component.

Findings include:

1. Observation on March 19, 2024, at 1:35 PM, revealed the exit door from the 1st floor Sun Porch to the outside could only be opened after several forceful tries, and continued to be difficult to open after the initial opening.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 1:35 PM, confirmed the door required excessive force to open.




 Plan of Correction - To be completed: 04/25/2024

Means of Egress General - exit location free of all obstructions to full use in case of an emergency

Maintenance Director adjusted/repaired the exit door from 1st floor Sun Porch to the outside to maintain egress free of obstructions.

Maintenance Director will make rounds around the facility to ensure means of egress to exit doors free of obstructions.

Monthly audits to be completed by Maintenance Director or designee to ensure means of egress to exit doors are free of obstructions and for ease of door opening.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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: EAST BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas to positively latch, in one of two Stair Towers within the component.

Findings include:

1. Observation on March 19, 2024, at 1:20 PM, revealed the rated door from the Kitchen into the stairtower had a hold-open device installed which would prevent the door from closing and latching, and is not on the fire alarm system to automatically release.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 1:20 PM, confirmed the door hold open device would not release upon activation of the fire alarm system.



 Plan of Correction - To be completed: 04/25/2024

Stairways and Smokeproof Enclosures

Maintenance Director checked the door from the kitchen and a high spot in the floor was catching the kitchen door and not a hold open device to prevent the door from closing and latching. A door stopper was installed behind the door to prevent door from catching on the high spot in the floor.

Maintenance Director will make rounds around the facility to ensure stairways and smokeproof enclosures are maintained.

Monthly audits times four and Quarterly audits to be completed by Maintenance Director or designee to ensure stairways and smokeproof enclosures are maintained.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Emergency Lighting:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: EAST BUILDING - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to perform functional tests of battery-powered emergency lighting source at the generator, in one of five smoke zones within the component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation verifying the 90 minute annual battery back-up emergency lighting test had been performed in the Generator Room.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the facility could not provide documentation that the annual test had been performed.


 Plan of Correction - To be completed: 04/25/2024

Emergency Lighting

Facility cannot retroactively correct for the documentation

Maintenance Director completed 90-minute back-up emergency tests of the battery-powered emergency lighting source at the generator, in one of five smoke zones within component and will provide the 90-minute annual documentation verifying the 90-minute annual battery back-up emergency lighting test was performed.

Monthly audits times four and semi-annual audits to be completed by Maintenance Director or designee to ensure 90-minute battery back-up emergency lighting test are performed.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Exit Signage:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: EAST BUILDING - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain provide documentation that exit signs were being inspected on a monthly basis, affecting the entire component.

Findings include:

1. Review of documentation on March 19, 2024, between 9:45 AM and 11:30 AM, revealed the facility lacked documentation verifying exit signs were visually inspected for the month of February thru August 2023.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the facility could not provide documentation that exit sign inspections were being performed.



 Plan of Correction - To be completed: 04/25/2024

Exit Signage

Facility cannot retroactively correct for the documentation from February 2023 through August 2023

Maintenance Director will complete and verify documentation of exit signs are visually inspected and are performed on a monthly basis.

Monthly audits times four and Quarterly audits to be completed by Maintenance Director or designee to ensure documentation of exit signs are visually inspected and are performed.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: EAST BUILDING - Component: 01 - Tag: 0324

Based on document review, observation, and interview, it was determined the cooking fire equipment protection system was not being inspected, semi-annually, in one of four smoke zones within the component.

Findings include:

1. Review of documentation and observation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the kitchen suppression system was not inspected on a semi-annual basis.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the inspection was not performed.




 Plan of Correction - To be completed: 04/25/2024

Cooking Facilities

Facility cannot retroactively correct, however documentation was provided to surveyor after initial inspection

Maintenance Director will follow up with the contracted services for the inspection documentation when kitchen suppression system inspection is performed on a semi-annual basis.

Semi-annual audits to be completed by Maintenance Director or designee to ensure documentation of kitchen suppression system inspection is performed on a semi-annual basis.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: EAST BUILDING - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to provide the smoke detector sensitivity testing, which serves the entire component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the smoke detectors had not had a sensitivity test in the past 2 years.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 12:30 PM, confirmed the smoke detector sensitivity test had not been performed in the last 2 years.




 Plan of Correction - To be completed: 04/25/2024

Fire Alarm System Testing and Maintenance

Facility cannot retroactively correct for the documentation for the past two years

Maintenance Director followed up with the contracted services for the smoke detectors for sensitivity test. Report from March 23, 2023 received and is on file

Yearly audit to be completed by Maintenance Director or designee to ensure documentation of smoke detectors for sensitivity test.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: EAST BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to perform the monthly owner's quick checks of portable fire extinguishers, in four of four smoke zones the component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility failed to provide monthly inspections between February and September 2023.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the facility failed to perform the owner's quick checks.



 Plan of Correction - To be completed: 04/25/2024

Portable Fire Extinguishers

Facility cannot retroactively correct for the documentation from February 2023 through August 2023

Maintenance Director will complete and verify documentation that Fire Extinguishers are inspected monthly.

Monthly audits to be completed by Maintenance Director or designee to ensure documentation that Fire Extinguishers are inspected monthly. Documentation will be on the fire extinguisher tags as well as on a spreadsheet.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Fire Drills: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.
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: EAST BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct and perform fire drills, one per shift per quarter, which affects the entire component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility did not perform fire drills, for the following shifts:

a. 1st quarter, 2nd shift;
b. 2nd quarter, 1st, 2nd and 3rd shifts;
c. 3rd quarter, 2nd and 3rd shifts;
d. 4th quarter, 1st and 3rd shifts.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the fire drills were not performed.





 Plan of Correction - To be completed: 04/25/2024

Fire Drills

Facility cannot retroactively correct

Maintenance Director to complete monthly fire drills for compliance for all shifts, one per shift per quarter.

Monthly audits times four and Quarterly audits to be completed by Maintenance Director or designee to confirm monthly fire drills are conducted for all shifts, one per shift per quarter.

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

Based on document review and interview, it was determined the facility failed to provide documentation that the annual fire door inspection was performed, throughout the component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility could not provide documentation that the annual fire door inspection had not been performed.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed documentation that rated doors were inspected in the last twelve months was not available for review.


 Plan of Correction - To be completed: 04/25/2024

Maintenance, Inspection & Testing - Doors

Facility cannot retroactively correct

Maintenance Director completed rounds checking the fire/smoke doors as well as purchased a fire/smoke door gauge to inspect the fire/smoke doors.

Weekly audits times four and Semi-annual audits to be completed by Maintenance Director or designee to confirm scheduling and documentation of fire/smoke doors are inspected/performed and inspection report has been filed in Life Safety book.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
Initial comments:Name: WEST BUILDING - Component: 02 - Tag: 0000


Facility ID #260202
Component 02
West Building

Based on a Medicare/Medicaid Recertification Survey completed on March 19, 2024, it was determined that Richfield Healthcare 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 two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Exit Signage:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: WEST BUILDING - Component: 02 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain provide documentation that exit signs were being inspected on a monthly basis, affecting the entire component.

Findings include:

1. Review of documentation on March 19, 2024, between 9:45 AM and 11:30 AM, revealed the facility lacked documentation verifying exit signs were visually inspected for the month of February thru August 2023.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the facility could not provide documentation that exit sign inspections were being performed.



 Plan of Correction - To be completed: 04/25/2024

Exit Signage

Facility cannot retroactively correct for the documentation from February 2023 through August 2023

Maintenance Director will complete and verify documentation of exit signs are visually inspected and are performed on a monthly basis.

Monthly audits times four and Quarterly audits to be completed by Maintenance Director or designee to ensure documentation of exit signs are visually inspected and are performed.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: WEST BUILDING - Component: 02 - Tag: 0345

Based on document review and interview, it was determined the facility failed to provide the smoke detector sensitivity testing, which serves the entire component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the smoke detectors had not had a sensitivity test in the past 2 years.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 12:30 PM, confirmed the smoke detector sensitivity test had not been performed in the last 2 years.


 Plan of Correction - To be completed: 04/25/2024

Fire Alarm System Testing and Maintenance

Facility cannot retroactively correct for the documentation for the past two years

Maintenance Director followed up with the contracted services for the smoke detectors for sensitivity test. Report from March 23, 2023 received and is on file

Yearly audit to be completed by Maintenance Director or designee to ensure documentation of smoke detectors for sensitivity test.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: WEST BUILDING - Component: 02 - Tag: 0355

Based on document review and interview, it was determined the facility failed to perform the monthly owner's quick checks of portable fire extinguishers, in four of four smoke zones the component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility failed to provide monthly inspections between February and September 2023.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the facility failed to perform the owner's quick checks.


 Plan of Correction - To be completed: 04/25/2024

Portable Fire Extinguishers

Facility cannot retroactively correct for the documentation from February 2023 through August 2023

Maintenance Director will complete and verify documentation that Fire Extinguishers are inspected monthly.

Monthly audits to be completed by Maintenance Director or designee to ensure documentation that Fire Extinguishers are inspected monthly. Documentation will be on the fire extinguisher tags as well as on a spreadsheet.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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: WEST BUILDING - Component: 02 - Tag: 0363

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

Findings include:

1. Observation on March 19, 2024, at 1:00 PM, revealed the corridor door to Resident Room 12 was dragging on the threshold and could not close and positively latch.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 1:00 PM, confirmed the door was obstructed from closing.






 Plan of Correction - To be completed: 04/25/2024

Corridor Doors

Maintenance Director adjusted/repaired corridor door to room 12.

Maintenance Director will make rounds around the facility to ensure corridor doors are unobstructed from closing and or positively latching.

Weekly audits times four and monthly audits to be completed by Maintenance Director or designee to ensure corridor doors are unobstructed from closing and or positively latching.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Fire Drills: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.
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: WEST BUILDING - Component: 02 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct and perform fire drills, one per shift per quarter, which affects the entire component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility did not perform fire drills, for the following shifts:

a. 1st quarter, 2nd shift;
b. 2nd quarter, 1st, 2nd and 3rd shifts;
c. 3rd quarter, 2nd and 3rd shifts;
d. 4th quarter, 1st and 3rd shifts.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed the fire drills were not performed.


 Plan of Correction - To be completed: 04/25/2024

Fire Drills

Facility cannot retroactively correct

Maintenance Director to complete monthly fire drills for compliance for all shifts, one per shift per quarter.

Monthly audits times four and Quarterly audits to be completed by Maintenance Director or designee to confirm monthly fire drills are conducted for all shifts, one per shift per quarter.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: WEST BUILDING - Component: 02 - Tag: 0761

Based on document review and interview, it was determined the facility failed to provide documentation that the annual fire door inspection was performed, throughout the component.

Findings include:

1. Review of documentation on March 19, 2024, between 10:00 AM and 11:30 AM, revealed the facility could not provide documentation that the annual fire door inspection had not been performed.

Interview with the Administrator and Director of Maintenance on March 19, 2024, at 11:30 AM, confirmed documentation that rated doors were inspected in the last twelve months was not available for review.


 Plan of Correction - To be completed: 04/25/2024

Maintenance, Inspection & Testing - Doors

Facility cannot retroactively correct

Maintenance Director completed rounds checking the fire/smoke doors as well as purchased a fire/smoke door gauge to inspect the fire/smoke doors.

Weekly audits times four and Semi-annual audits to be completed by Maintenance Director or designee to confirm scheduling and documentation of fire/smoke doors are inspected/performed and inspection report has been filed in Life Safety book.

Results of the audit to be reviewed at the monthly QAPI/QAA meetings.

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