Nursing Investigation Results -

Pennsylvania Department of Health
 ELM TERRACE GARDENS
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ELM TERRACE GARDENS
Inspection Results For:
There are  33 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.
ELM TERRACE GARDENS - 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 13, 2020, it was determined that Elm Terrace Gardens had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
*[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]:

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

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

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

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

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

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

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on observation and interview, it was determined the facility failed to conduct an additional required exercise of its Emergency Preparedness Plan.

Findings include:

1. Document review on January 13, 2020, at 10:50 am, revealed the facility did not conduct a tabletop exercise of their emergency plan within the previous 12 months.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the facility did not conduct secondary exercise of the emergency preparedness plan.





 Plan of Correction - To be completed: 02/28/2020

Maintenance Director and/or designee will conduct an additional tabletop exercise of the facility emergency plan per the regulatory requirements. Maintenance Director will present documentation supporting this exercise to the Quality Council for review to ensure compliance.
Initial comments:Name: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0000


Facility ID #310802
Component 03
D Building

Based on a Medicare/Medicaid Recertification Survey completed on January 13, 2020, it was determined that Elm Terrace Gardens 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 six-story, Type II (222), fire resistive construction, with a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain portable, accurate floor plans outlining designated rated partitions, affecting the entire facility.

Findings include:

1. Document review on January 13, 2020, at 11:50 am, revealed the facility failed to provide accurate portable Life Safety Code Floor Plans that included the following information:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan.
e. Required Exits should be clearly noted; and
f. Shafts Walls.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the inaccurate portable floor plans.





 Plan of Correction - To be completed: 02/28/2020

The Maintenance Director will develop accurate portable Life Safety Code Floor Plans that included the following information: Smoke Barrier Walls (outside wall to outside wall), Fire Barrier Walls (2-hour walls), Horizontal Exits, Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated, Required Exits will be clearly noted, and Shafts Walls. Floor plans will be reviewed by the Quality Council to ensure requirement is met.
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: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain that stairwell enclosures were free of unsealed penetrations in two of three stairwells within the facility.

Findings include:

1. Observation on January 13, 2020, between 1:50 pm and 2:45 pm, revealed the following unsealed penetrations:

a. 1:50 pm, In stair 11 there was blue, yellow and red data wires on the 1st floor, above the door into the stair tower.
b. 2:15 pm, In stair 12 there was a copper pipe, data lines (two locations) and a black wire on the 2nd floor, above the door into the stair tower.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the unsealed penetrations.





 Plan of Correction - To be completed: 02/28/2020

The Maintenance Director will seal penetrations in rated stair tower enclosures in the following locations using through penetration fire stop system number C-BJ-3016 with corresponding 3M through penetration fire stop system rating 3M Fire Barrier Sealant: In stair 11, above the door into the stair tower and in stair 12, above the door into the stair tower. Maintenance Director and/or designee will complete random audits monthly of stair towers to ensure fire resistant rating and present to Quality Council to ensure compliance.
NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0311

Based on observation and interview, it was determined that the facility failed to ensure that elevator shafts were maintained and walls free of unsealed penetrations on one of five levels within the facility.

Findings include:

1. Observation made on January 13, 2020 at 11:50 am, revealed an unsealed penetration by a sprinkler pipe, in the side wall of the elevator shaft near the bottom of the shaft.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the unsealed penetration.






 Plan of Correction - To be completed: 02/28/2020

The Maintenance Director will utilize a qualified vendor to seal penetration in the elevator shaft by the sprinkler pipe in the side wall using through penetration fire stop system number C-BJ-3016 with corresponding 3M through penetration fire stop system rating 3M Fire Barrier Sealant. Maintenance Director will utilize a qualified vendor to audit the elevator shaft for penetrations monthly for 3 months then quarterly thereafter. Findings will be presented to the Quality Council to ensure compliance.
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: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0353

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

Findings include:

1. Observation on January 13, 2020, at 11:35 am, revealed a Disk 500 error on the fire pump controller in the basement.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed error on the fire pump.

2. Observation on January 13, 2020, at 12:06 pm, revealed a sprinkler pushed up in its escutcheon in Maintenance Storage in the basement.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the sprinkler pushed up in its escutcheon.

3. Observation on January 13, 2020, between 1:30 pm and 2:45 pm, revealed storage within 18" of the sprinkler in the following locations:

a. 1:30 pm, Clean Linen near Physical Therapy on the 1st floor.
b. 1:40 pm, Storage Room across from resident room 108 on the 1st floor.
c. 1:42 pm, closet in the Director of Nursing office on the 1st floor.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed storage within 18" of the sprinkler in the above locations.

4. Observation on January 13, 2020, at 1:42 pm, revealed excessive debris on the sprinkler in the heat pump room in Suite 216, on the 2nd floor.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the excessive debris.






 Plan of Correction - To be completed: 02/28/2020

Maintenance Director will utilize a qualified vendor to remedy the Disk 500 error on the fire pump controller in the basement. Maintenance Director will utilize a qualified vendor to repair the sprinkler pushed up in its escutcheon in Maintenance Storage in the basement. Maintenance Director and/or designee corrected storage within 18" of the sprinkler in the following locations: Clean Linen near Physical Therapy on the 1st floor, Storage Room across from resident room 108 on the 1st floor, and closet in the Director of Nursing office on the 1st floor. Maintenance Director will re-educate staff on proper storage to ensure meeting regularly requirements. Maintenance Director cleared the excessive debris on the sprinkler in the heat pump room in Suite 216, on the 2nd floor. Maintenance Director and/or designee will conduct random monthly audits of the fire pump controller in the basement, storage rooms to ensure 18 inch regulatory requirement is met, and sprinkler heads for debris and present to Quality Council monthly to ensure compliance.
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: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain that smoke barrier walls were free of unsealed penetrations, affecting 4 of 7 smoke compartments within the facility.

Findings include:

1. Observation made on January 13, 2020, at 11:50 am and 2:45 pm, revealed the following locations had smoke barrier wall penetrations:

a. 11:50 am, smoke barrier wall near the elevator machine room in the basement, above the smoke doors by several flexible conduits.
b. 12:08 pm, smoke barrier wall near Maintenance Storage in the basement, by an abandoned junction box without a cover plate.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the penetrations.






 Plan of Correction - To be completed: 02/28/2020

The Maintenance Director will seal penetrations in smoke compartments in the following locations using through penetration fire stop system number C-BJ-3016 with corresponding 3M through penetration fire stop system rating 3M Fire Barrier Sealant: Smoke barrier wall near the elevator machine room in the basement, above the smoke doors by several flexible conduits and smoke barrier wall near Maintenance Storage in the basement, by an abandoned junction box without a cover plate. Maintenance Director and/or designee will complete random audits monthly of smoke compartments to ensure fire resistant rating and present to Quality Council to ensure compliance.
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: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0912

Based on observation and interview, it was determined the facility failed to ensure electrical devices in the vicinity of a water source were connected to a GFCI type circuit, affecting 1 of 7 smoke compartments within the facility.

Findings include:

1. Observation made on January 13, 2020, at 1:26 pm, 1st floor, revealed inside the physical therapy area, a hydrocollator plugged into a non-GFCI type outlet.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the hydrocollator was plugged into a non-GFCI type outlet.






 Plan of Correction - To be completed: 02/28/2020

Maintenance Director and/or designee will install GFCI type outlet to use for hydrocollator in the physical therapy area. Maintenance Director and/or designee will ensure hydrocollator is plugged into GFCI outlet monthly and present findings to the Quality Council to ensure compliance.
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: D BUILDING (SNF NEW ADDITION "D" WING) - Component: 03 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator, which provides emergency power to the entire facility.

Findings include:
1. Document review performed on January 13, 2020, at 8:00 am, revealed the facility could not produce documentation showing that a 3-year, 4-hour exercise of the generator had been performed.

Interview at the exit conference with the Maintenance Director on January 13, 2020, at 2:45 pm, confirmed the facility could not produce documentation for the required exercise.






 Plan of Correction - To be completed: 02/28/2020

Maintenance Director will utilize a qualified vendor to perform a 3-year, 4-hour exercise of the generator. Documentation will be maintained by the Maintenance Director and presented to the Quality Council to ensure compliance.

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