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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 36 surveys for this facility. Please select a date to view the survey results.

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GREENTREE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 20, 2024, it was determined that Greentree Skilled Nursing and Rehabilitation Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program:

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.

§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Observations:
Name: - Component: -- - Tag: 0037

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain documentation of staff training and testing.

Findings include:

1. Interview and documentation review on March 20, 2024, at 8:44 a.m., revealed the facility lacked documentation of initial and annual training for all new and existing staff.

Interview with the Facility Administrator and Maintenance Staff on March 20, 2024, at 2:00 p.m., confirmed the missing documentation for initial training and annual training for new and existing staff.

Plan of Correction - To be completed: 05/04/2024

The Education Department located the Emergency Preparedness training records completed Quarter 4 for all employees. Employees complete will Emergency Planning training on hire and annually thereafter. The Education Department will monitor completion.

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..

Observations:
Name: - Component: -- - Tag: 0041
Based on a review of the facilities Emergency Preparedness (EP) Plan, it was determined the facility failed to assess the need for emergency power and stand by systems based on their emergency plan and risk assessment.

Findings include:

1. Interview and documentation review on March 20, 2024, at 8:44 a.m., revealed the EP Plan failed to include emergency and standby power systems based upon the facility's established emergency plan, risk assessment, policies and procedures.

Interview with the Facility Administrator, Maintenance Staff, on March 20, 2024, at 2:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 05/04/2024

Emergency Preparedness Plan will be updated to include emergency and standby power systems. Plan will be reviewed and monitored for 6 months by the Senior Maintenance Director.

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

Facility ID# 381502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 20, 2024, it was determined that Greentree Skilled Nursing and Rehabilitation, 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 three-story, Type II (111), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to perform the monthly exit sign inspection for four of 12 months.

Findings Include:

Document review on March 20, 2024, at 8:35 a.m., revealed the facility lacked documentation for the monthly exit sign inspection from November 2024 until March of 2024.

Interview with the Facility Administrator and Maintenance Staff on March 20, 2024, at 2:30 p.m., confirmed the facility lacked documentation for the above listed exit sign inspections at the time of the survey.

Plan of Correction - To be completed: 05/04/2024

The Maintenance Department located the exit sign inspection forms for November through March 2024. All Maintenance staff will be trained on logging exit sign inspections and placing the forms in the Life Safety under. Life Safety Binder will be checked to ensure inspection form are present every month for 6 months by the Senior Maintenance Director.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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

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

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

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance, affecting one of 13 smoke compartments.

Findings include:

1. Observation on March 20, 2024, at 11:00 a.m., revealed the door to the oxygen storage closet located on the first floor next to B stairwell failed to latch when tested.

Interview with the Facility Administrator and Maintenance Staff on March 20, 2024, at 2:00 p.m., confirmed the hazardous enclosure deficiency.

Plan of Correction - To be completed: 05/04/2024

Maintenance staff will repair the first floor door latch next to B stairwell. This door will be placed on monthly door check scheduled. Senior Maintenance Director will review door check form to ensure door is working properly every month for next 6 months.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on documentation review, observation, and interview, it was determined the facility failed to perform two of twelve monthly kitchen fire suppression system inspections.

Findings include:

1. Document review and observation on March 20, 2024, at 11:45 a.m., revealed the monthly inspections for the kitchen fire suppression system in the rehab addition were not completed in November and December.

Interview with the Facility Administrator and Maintenance Staff on March 20, 2024, at 2:00 p.m., confirmed the facility lacked documentation for the monthly kitchen fire suppression system inspections.

Plan of Correction - To be completed: 05/04/2024

Maintenance Department found missing monthly kitchen fire suppression system form. This from will be placed in the Life Safety Binder and Senior Maintenance Director will check Binder monthly for next 6 months to make sure form is present.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 documentation review and interview, it was determined the facility failed to perform the required fire alarm system inspection and testing within the last 24 months.

Findings Include:

1. Review of documentation on March 20, 2024, revealed the facility lacked documentation for the following required fire alarm system maintenance and testing:

a) 8:45 a.m., the facility lacked documentation for the semi-annual visual inspection;
b) 8:47 a.m., the facility lacked documentation for required biennial smoke detector sensitivity testing.

Interview with the Administrator and maintenance staff on March 20, 2024, at 2:00 p.m., confirmed the facility lacked documentation, at the time of the survey, for the above listed testing.

Plan of Correction - To be completed: 05/04/2024

Maintenance Department found semi annual visual inspection form and sensitivity test. Both documents will be filed in the Life Safety Binder. Senior Maintenance Director will check Binder to ensure documents are present every month for the next 6 months.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility.

Findings include:

1. Observation on March 20, 2024, revealed the following automatic sprinkler system deficiencies:

a) 8:40 a.m., the facility failed to provide documentation for the fourth quarter sprinkler system inspection;
b) 9:30 a.m., there were missing ceiling tiles in the folding room of the main laundry.

Interview with the Facility Administrator and Maintenance staff on March 20, 2024, at 2:00 p.m., confirmed the above listed sprinkler deficiencies.

Plan of Correction - To be completed: 05/04/2024

Maintenance Department found the 4th quarter sprinkler inspection. Form will be filed in Life Safety Binder. Senior Maintenance Director will check Binder every month for next 6 months to ensure form is present.

Ceilingtile has been repaired in folding room of main laundry. maintenance staff will check monthly for missing and damaged ceiling tile, every month for next 6 months.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in three instances, for three of over 100 doors inspected.

Findings include:

1. Observation on March 20, 2024, revealed the following doors would not positively latch, when tested.

a) 10:03 a.m., the door to Room 305 would not positively latch on inspection;
b) 10:10 a.m., the door to Room 305 would not positively latch on inspection;
c) 10:15 a.m., the door to the Social Services Room would not positively latch on inspection.

Interview with the Facility Administrator and Maintenance Staff on March 20, 2024, at 2:00 p.m., confirmed the above listed corridor door deficiencies.

Plan of Correction - To be completed: 05/04/2024

Latches fro room 305 and social services have been repaired. These doors will be added to the monthly door inspection list. Senior Maintenance Director will check list to ensure completeness every 6 months for the next 6 months.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain the smoke dampers in accordance with NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives..

Findings include:

1. Document review on March 20, 2024 at 9:02 a.m., revealed the the facility failed to provide documentation of repair of deficiencies found during the four year smoke damper inspection.

Interview with the Facility Administrator and Maintenance Staff on March 20, 2024, at 2:30 p.m., confirmed the facility lacked the damper repair documentation.

Plan of Correction - To be completed: 05/04/2024

Maintenance Director will call damper repair company for repair. Repairs will be included in the Life Safety Binder. Senior Maintenance Director will check Binder every month for the next 6 month to make sure facility is in compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on March 20, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The annual 90 minute load bank;
b) The annual fuel quality test;
c) The four hour load test that is required every three years.

Interview with the Facility Administrator and Maintenance Staff- on March 20, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.

Plan of Correction - To be completed: 05/04/2024

Maintenance Director will obtain the documentation emailed to facility and place it in the Life Safety Binder. Senior Maintenance Director will check bind to ensure facility is in compliance every month for the next 6 months.

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