Pennsylvania Department of Health
ST. IGNATIUS NURSING & REHAB CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. IGNATIUS NURSING & REHAB CENTER
Inspection Results For:

There are  47 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.
ST. IGNATIUS NURSING & REHAB 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 April 10, 2024, it was determined St. Ignatius Nursing & Rehab Center had deficiencies having the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 482.15(c)(1), 483.475(c)(1), 483.73(c)(1), 484.102(c)(1), 485.542(c)(1), 485.625(c)(1), 485.68(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1) STANDARD Names and Contact Information: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(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 460.84(c)(1), 482.15(c)(1), 483.73(c)(1), 483.475(c)(1), 484.102(c)(1), 485.68(c)(1), 485.542(c)(1), 485.625(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1).

[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at 482.15(c) and CAHs at 485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

Based on document review and interview, it was determined the facility failed develop and maintain an emergency preparedness communication plan as required.

Findings include:

Document review on April 10, 2024, at 9:30 a.m., revealed names and contact information for current staff had not been updated in the emergency preparedness plan.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/19/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

Names and contact information for current staff has been updated in the emergency preparedness plan.


Initial comments:Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0000


Facility ID# 450602
Component 01
Main Building & Sunroom Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 10, 2024, it was determined St. Ignatius Nursing & Rehab Center - Main Building & Sunroom Addition 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 five-story, Type II (000), unprotected non-combustible building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating of the building construction, affecting the entire facility.

Findings include:

Document review on April 10, 2024, at 10:00 a.m., revealed the facility was classified as a five-story, Type II (000) unprotected non-combustible construction, with a basement, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by three stories.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the story height exceeds the maximum allowance for this construction type by three stories.




 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

K-161, was cited on earlier LSC surveys. On CMS guidance, PA DOH approved a time-limited waiver of this requirement. Subsequently, CMS changed the FSES calculation, relieving health care occupancies of the NFPA standard requiring fire-protective coating for structural steel supports in buildings of five stories or more.

A life safety consultant was retained to conduct an FSES inspection. A copy of the FSES was provided to the on-site surveyor last year and this year.
NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions, affecting two of six levels.

Findings include:

1. Observation on April 10, 2024, at 10:30 a.m., revealed the basement exit door by maintenance required excessive force to open.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the excessive force to open the exit door.


2. Observation on April 10, 2024, at 11:45 a.m., revealed on the third floor East stair tower had debris strewn on the landing.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the debris in the stair tower.







 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The Basement exit door has been repaired by maintenance and now opens properly.

All exit doors will continue to continue to be inspected in the normal preventative maintenance program. The results will continue to be recorded on the facilities PM log.

The third-floor east stair tower has been cleaned along with all stair towers. Cleaning of stair towers has been added to a day housekeeper's assignment sheet.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.

The Director of Plant Operations will continue to report findings to the Performance Improvement (PI) team monthly for three months and afterward as needed.
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: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors were sealed to maintain the smoke resistive construction, affecting one of six levels within the facility.

Findings include:

Observation made on April 10, 2024, at 10:40 a.m., revealed an unsealed penetration of the ceiling in the basement electric room.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the unsealed penetration.






 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The penetration of the ceiling in the basement electrical room has been sealed with a fire-rated caulk.

The Director of Plant Operations will continue to monitor and maintain compliance.


NFPA 101 STANDARD Hazardous Areas - 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.
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 & SUNROOM ADDITION - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain separation of spaces by smoke resistant doors to hazardous areas, in sprinklered locations, affecting one of six levels.

Findings include:

Observation on April 10, 2024, revealed the following deficiencies of hazardous area enclosures:

a. 11:30 a.m., on the fourth floor West soiled room door failed to latch when tested.
b. 11:35 a.m., on the fourth floor East soiled room door propped open with a floor sign.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the hazardous area deficiencies.








 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The fourth-floor West soiled room door has been repaired and now latches when tested.

The fourth-floor East soiled room door is no longer propped open.

All staff has been in-serviced on the importance of not propping open doors.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.


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

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating of vertical enclosures for kitchen exhaust ducts, affecting one of six levels.

Findings include:

Document review on April 10, 2024, at 10:00 a.m., revealed the facility dietary range hood exhaust duct lacked a two-hour fire resistive enclosure through to the roof.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the dietary range hood exhaust duct enclosure did not maintain the proper fire rating.





 Plan of Correction - To be completed: 06/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

A Life Safety Code consultant conducted an inspection of the dietary range hood exhaust duct through to the roof.

The consultant verified that the current exhaust system includes: (1) a 2-hour fire-rated double island canopy hood; (2) heavy-gauge horizontal ductwork from the hood and spanning the kitchen ceiling; and (3) 2-hour fire-rated vertical shaft to the roof from the horizontal ductwork with.

To achieve full compliance with the standard, the consultant proposed: (1) repairing the assembly at the bottom of the vertical shaft; (2) adding a fire-resistive wrap around the horizontal ductwork to achieve a 2-hour rating; and (3) eliminating the ductwork that branches from the horizontal ductwork to the pot-wash area.

An architect is preparing an updated schematic for the dietary range hood exhaust system and will be submitting it to LSC Plan review.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 & SUNROOM ADDITION - Component: 01 - Tag: 0345

Based on document review and interview, itt was determined the facility failed to ensure Fire Alarm inspections were conducted within the required timeframe, affecting one of two inspections.
Findings include:
Document review and interview on April 10, 2024, at 8:45 a.m., revealed the facility could not produce documentation that the most recent annual fire alarm inspection had been performed within 1 year prior to the annual fire alarm inspection performed in February 2023.
Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the above deficiency.











 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The contracted fire-safety company is scheduled to complete the annual fire alarm inspection on May 1,2 2024.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.


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

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting two of three gauges.

Findings Include:

Observation on April 10, 2024, at 10:50 a.m., revealed in basement sprinklerr room, a sprinkler gauge was dated 2018, exceeding the 5-year service interval

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the gauge was beyond the 5-year service interval.










 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

In the basement sprinkler room, the sprinkler gauge dated 2018, has been scheduled for 5-year service inspection.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.


NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of linen chutes and discharge rooms, affecting two of six levels.

Findings include:

1. Observation made on April 10, 2024 at 10:47 a.m., revealed in the West Wing basement Laundry Chute room, the access door is binding to the frame and failed to positively latch.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the door deficiencies.


2. Observation on April 10, 2024, at 11:50 a.m., revealed on the third floor, the west linen chute door failed to close and latch when tested.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the chute door deficiency.






 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

In the West Wing basement Laundry Chute room, the access door has been repaired and now positively latches.

The Administrator and Director of Plant Operations will monitor and maintain compliance.


NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0911

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

Findings include:

Observations on April 10, 2024, revealed the following electrical wiring deficiencies:

a. 10:45 a.m., basement boiler room, exposed wires at circulating pump.
b. 10:55 a.m., basement laundry, 3- electrical panels missing panel schedules.
c. 11:00 a.m., basement laundry, above electrical panel, exposed wires from old panel.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.





 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

An Electrician has been retained to repair all wiring issues cited.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices, affecting two of six levels.

Findings include:

Observations on April 10, 2024, revealed the following electrical deficiencies:

a. 11:30 a.m., on the fourth floor Nurses office, microwave and fridge plugged into surge protector.
b. 11:50 a.m., on the first floor Annex, microwave and toaster plugged into surge protector.
c. 12:00 p.m., on the first floor Annex- RNAC office, microwave plugged into surge protector.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the unauthorized electrical devices.





 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

All non-medical electrical equipment has been removed from surge protectors.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 & SUNROOM ADDITION - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, affecting two of six levels.

Findings include:

1. Observation on April 10, 2024, at 11:05 a.m., revealed on the basement floor, Oxygen Storage Room door failed to self-close and latch due to a damaged coordinator.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 pm, confirmed the damaged door coordinator.


2. Observations on April 10, 2024 at 11:55 a.m., revealed on the second floor, missing signage on the door of the West Wing main bathroom where oxygen is stored.

Exit Interview with the Administrator and Maintenance Director on April 10, 2024, at 1:20 p.m., confirmed the the missing signage.









 Plan of Correction - To be completed: 05/15/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The basement floor, Oxygen Storage Room door now has a new coordinator.

The second floor, on the door of the West Wing main bathroom where oxygen is stored now has the appropriate signage.

The Administrator and Director of Plant Operations will continue to monitor and maintain compliance.

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