Pennsylvania Department of Health
CARE PAVILION NURSING AND REHABILITATION CENTER
Building Inspection Results

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CARE PAVILION NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  49 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.
CARE PAVILION 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 January 16, 2024, at Care Pavilion 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 01 - Component: 01 - Tag: 0000


Facility ID# 292002
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on January 16, 2024, it was determined that Care Pavilion Nursing And Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire resistive building, with a basement and a sub-basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility did not maintain the fire resistance of fire barriers, affecting two of six levels in the facility.

Findings include:

1. Observations on January 16, 2024, between 11:17 a.m. and 11:37 a.m., revealed fire barrier doors did not close together in the following locations:

a. 11:17 a.m., on the third floor, 3E fire barrier;
b. 11:37 a.m., on the second floor, 2E fire barrier.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the doors failed to close together.

2. Observation on January 16, 2024, at 11:37 a.m., revealed, on the second floor, an open penetration by MC cables above the 2E fire barrier doors.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the open penetration.




 Plan of Correction - To be completed: 02/08/2024

Fire barrier doors on 3 east and 2 east were repaired.

The penetration above fire door 2 e located near MC cable was repaired.
Penetrations were repaired using System No. W-L-3195

Maint. Director/designee will audit fire doors for closure and penetrations weekly x3 then monthly for 3 months to ensure compliance with results reported to the QAPI committee.

NFPA 101 STANDARD Egress Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain egress doors with special locking arrangements, affecting one of six levels in the facility.

Findings include:

Observation on January 16, 2024, at 11:05 a.m., revealed on the fourth floor, the staff did not know the exit code for exit door 4W4.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the staff did not know the exit code.




 Plan of Correction - To be completed: 02/08/2024

When the fire alarm is activated the mag locks release.

When codes are changed monthly maintenance communicates the new code to all department directors. The department directors communicate the changed code to their staff.

Random audits will be completed weekly, staff will be interviewed to ensure they are aware of the current code.

Random audits will be conducted weekly x 3 weeks then monthly for 3 to ensure compliance with results reported to the QAPI committee.

NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

Based on observation and interview, it was determined the facility failed to maintain illumination of paths of egress, affecting one of six levels in the facility.

Findings include:

Observation on January 16, 2024, at 11:12 a.m., revealed, on the third floor, the lights in the stairwell landing of exit door 3W4 were not working.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lights were not working.




 Plan of Correction - To be completed: 02/08/2024

3 West landing exit door 4 was repaired.

Audit of stairwell tower light fixtures will be completed by Maintenance Director/designee weekly x 3 weeks then monthly x3 with results reported to the QAPI committee.

NFPA 101 STANDARD Exit Signage:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain and inspect exit signage, affecting the entire facility.

Findings include:

Document review on January 16, 2024, at 8:30 a.m., revealed the facility could not produce documentation of monthly exit sign inspections.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 02/08/2024

Confirmation of the inspection of the exit signage is in the Life Safety book. This information was in the book at the time of the survey.

Weekly audits of exit signage will be completed by Maint Dir/designee weekly x3 then monthly x3 to ensure compliance with results report to the QAPI committee.

NFPA 101 STANDARD Cooking Facilities: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.
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 01 - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility did not maintain and inspect the kitchen exhaust hood suppression system, affecting the entire facility.

Findings include:

Document review on January 16, 2024, at 8:30 a.m., revealed the facility could not provide documentation of the following:

a. Kitchen exhaust hood suppression system semi-annual testing within six months of 3/8/2023;
b. Kitchen exhaust hood cleaning within six months prior to 1/9/2024.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/08/2024

Hood inspection was completed on 1/9/2024.

Maint. Director educated on the need for semiannual cleaning, inspection, and documentation.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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 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: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility.

Findings include:

Document review on January 16, 2024, at 8:30 a.m., revealed the facility could not produce documentation of an annual fire alarm inspection.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/08/2024

The annual fire alarm inspection was completed on 10/26/2023.
Maintenance Director educated on the need to updated documentation available for review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 01 - Component: 01 - Tag: 0353

Based on document review, observation, and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

1. Document review on January 16, 2024, at 8:30 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. Second and Fourth quarter sprinkler inspections;
b. Five year internal valve and pipe inspection.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lack of documentation.

2. Observation and interview on January 16, 2024, between 11:22 a.m. and 12:30 p.m., revealed missing or broken ceiling tiles in the following locations:

a. 11:22 a.m., on the third floor, east Locker Room;
b. 12:30 p.m., lower level basement, Biohazard room.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the missing or broken ceiling tiles.

3. Observation on January 16, 2024, at 12:29 p.m., revealed, in the basement Loading Dock Storage, excessive debris on the sprinklers.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the excessive debris on the sprinklers.




 Plan of Correction - To be completed: 02/08/2024

The second and 4th quarter sprinkler inspections and the 5-year inspection of internal valve and pipe inspections are now available for review. This includes the date the sprinkler was last checked, who provided the system check and water supply source.

Ceiling tiles 3rd floor east locker and lower-level basement biohazard were replaced.

Debris on sprinkler head in loading dock area was cleaned.

Maint. Director educated on the need for documentation of sprinkler inspections and valve and pipe inspections.

Weekly random audits of ceiling tiles and sprinkler heads will be completed weekly x3 then monthly x3 to ensure compliance. Results will be reported to the QAPI Committee x3 months.

NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting two of six levels in the facility.

Findings include:

Observation on January 16, 2024, between 12:16 p.m. and 12:34 p.m., revealed blocked portable fire extinguishers in the following locations:

a. 12:16 p.m., basement Kitchen, by a trash can;
b. 12:34 p.m., lower level basement by the Mechanical Room, by wheelchairs.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the blocked portable fire extinguishers.




 Plan of Correction - To be completed: 02/08/2024

The trash can blocking the fire extinguisher was moved.
The wheelchair on the lower level blocking the fire extinguisher was moved.

Staff will be educated on not blocking fire extinguishers throughout facility.

Random audits will be conducted weekly x 3 weeks then monthly x 3 to ensure compliance with results reported to the QAPI committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting three of six levels in the facility.

Findings include:

Observations on January 16, 2024, between 11:24 a.m. and 12:27 p.m., revealed open penetrations in the smoke barriers in the following locations:

a. 11:24 a.m., on the third floor, 3E smoke barrier by resident room 365, by an MC cable;
b. 11:32 a.m., on the third floor, 3E smoke barrier by resident room 353, by a sprinkler pipe;
c. 12:05 p.m., on the first floor, 1E smoke barrier by resident room 152, by data cables;
d. 12:27 a.m., lower level basement, smoke barrier, by electric cables and an unsealed conduit end.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the open penetrations.





 Plan of Correction - To be completed: 02/08/2024



3 east by room 365, 353, 1 east room 152, lower-level basement smoke barrier penetrations were repaired using System No. W-L-3195.

Random audits of smoke barriers will be completed weekly x3 then monthly x3 to ensure no penetrations are present.
Results will be reported to the QAPI committee x3 months.

NFPA 101 STANDARD Utilities - Gas and Electric:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting five of six levels in the facility.

Findings include:

1. Observations on January 16, 2024, between 11:00 a.m. and 12:17 a.m., a credenza within three feet of the electrical panels in the below locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

a. 11:00 a.m., on the fourth floor, West Nurses' Station;
b. 11:10 a.m., on the third floor, West Nurses' Station;
c. 11:47 a.m., on the second floor, West Nurses' Station;
d. 12:17 p.m., basement Kitchen, by a refrigerator.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the improper storage in front of the electrical panels.

2. Observations on January 16, 2024, between 11:24 a.m. and 12:01 p.m., revealed open and/or unsecured junction boxes in the following locations:

a. 11:24 a.m., on the third floor, 3E smoke barrier by resident room 365;
b. 11:32 a.m., on the third floor, 3E smoke barrier by resident room 353;
c. 11:51 a.m., on the second floor, 2E Elevator 2;
d. 11:56 a.m., on the first floor, 1W smoke barrier;
e. 11:59 a.m., on the first floor, Elevator 3;
f. 12:01 p.m., on the first floor, 1E smoke barrier.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the open and/or unsecured junction boxes.

3. Observation on January 16, 2024, at 11:51 a.m., revealed, on the second floor, abandoned and exposed wiring above the ceiling outside the 2E Elevator 2.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the abandoned and exposed wiring.





 Plan of Correction - To be completed: 02/08/2024

All items were removed that were blocking electrical panels.

Basement kitchen refrigerator will be moved.

All junction boxes will be closed and secured.

Staff educated on requirement of not blocking electrical panels.
Maintenance educated on NFPA 70 .

NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain and inspect fire doors, affecting the entire facility.

Findings include:

Document review on January 16, 2024, at 8:30 a.m., revealed the facility could not provide documentation of an annual fire door inspection.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/08/2024

The annual fire door inspection was completed 1/5/2024. Documentation is in the life safety book.

Fire doors will be audited weekly for 3 weekx3 then monthly x3

Maintenance Director will have this information available in the documentation going forward.

NFPA 101 STANDARD Electrical Systems - Receptacles:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles, affecting one of six levels in the facility.

Findings include:

Observation on January 16, 2024, at 12:15 p.m., revealed, in the basement, the electrical receptacle across from the dietary Storage was broken.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the broken electrical receptacle.



 Plan of Correction - To be completed: 02/08/2024

The electric receptical across from dietary storage was repaired.

Maintenance director/designee will conduct an audit of electrical receptacles weekly x3 for 3 weeks to ensure compliance.
Results will be reported to the QAPI Committee x3 months.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on January 16, 2024, at 8:30 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. Weekly inspection of battery voltage;
b. Monthly inspection of battery conductance prior to 10/2023;
c. Annual 90 minute load bank;
d. Generator preventative maintenance showing no evidence of wet stacking;
e. 3 year, 4 hour load test;
f. Annual fuel quality test.

Exit interview with the Administrator and the Maintenance Director on January 16, 2024, at 12:45 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 02/08/2024

Annual fuel quality test was performed on 11/8/2023.

Wet stacking documentation completed on 11/8/23.

Fuel sample was completed 11/8/2023.

3-year 4-hour test was completed 5/1/2023.

Annual 90-minute load bank test documentation available.

Monthly inspection of battery conductance will be done weekly for 3 weeks then monthly x3

Weekly inspection of battery voltage will be done weekly during generator testing results uploaded in TELS.

Maintenance Director will be educated on having the documentation available for review.


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