Pennsylvania Department of Health
ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  44 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. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE - 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 25, 2024, it was determined that St. John Neumann Center for Rehabilitation & Healthcare, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.





 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: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(a), 416.54(a), 418.113(a), 441.184(a), 460.84(a), 482.15(a), 483.73(a), 483.475(a), 484.102(a), 485.68(a), 485.542(a), 485.625(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at 482.15 and CAHs at 485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated at least annually, for one of one plan.

Findings include:

Document review on March 25, 2024, at 10:30 a.m., revealed the facility failed to conduct an annual review of the Emergency Preparedness Plan.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/14/2024

1.The emergency plan was reviewed on 11-27-2023. Copy of the annual review is now placed in the front of the binder and a copy in the life safety binder.
2.NHA/designee will continue to review the plan annually.
3.Don/designee will audit the review of the plan annually x1.

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


Facility ID# 452202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 25, 2024, it was determined St. John Neumann Center for Rehabilitation & Healthcare 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 two-story, Type II (000), unprotected noncombustible building, with three partial basements, that is fully sprinklered.






 Plan of Correction:


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

Based on observation and interview, it was determined the facility failed to maintain delayed-egress doors, affecting one of three levels.

Findings include:

Observation on March 25, 2024, at 11:10 a.m., revealed, on the first floor, the kitchen exit egress door failed to release after pushing on the door for fifteen seconds, as indicated on signage.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the delayed egress door deficiency.





 Plan of Correction - To be completed: 05/14/2024

1.The kitchen door vendor has been scheduled for repair.
2.NHA/Designee will educate the dietary manager on maintaining a delayed egress door.
3.Audit of the kitchen door functionality will be checked weekly X 2 then monthly x 2.
4.Results of audit to be reported at QAPI.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain the fire-resistance rating of stair towers, affecting one of three levels.

Findings include:

Observation on March 25, 2024, at 12:15 p.m., revealed 600 exit C stairway door had non-rated hardware installed and 2-open holes.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the stair tower door deficiencies.




 Plan of Correction - To be completed: 05/14/2024

1.The exit C hardware is replaced with fire rated hardware and 2 open holes covered with fire rated material.
2.NHA/Designee will in-service maintenance department to ensure facility fire doors are fitted with fire rated materials only.
3.Maintenance director to complete a random audit of fire rated doors to ensure they are properly fitted weekly x 2, then monthly x 2.
4.Results of audit to be reported at QAPI.

NFPA 101 STANDARD Illumination of Means of Egress:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

Based on observation and interview, it was determined that the facility failed to ensure continuous illumination of means of egress, affecting two of three levels.

Findings include:

Observation on March 25, 2024, at 11:55 a.m., revealed 700 basement stairway had a light out.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the burned-out bulb.




 Plan of Correction - To be completed: 05/14/2024

1.Basement stairway light is replaced.
2.NHA/Designee to in-service maintenance department on checking and replacing facility lights.
3.The maintenance director will complete a random audit to assure lights are working within the facility weekly x 2 then monthly x 2.
4.Results of audit to be reported at QAPI.

NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of three levels.

Findings include:

Document review on March 25, 2024, at 9:30 a.m., revealed the facility lacked documentation of the following required tests of the battery back-up lighting:

a. monthly 30-second testing since October 9, 2023.
b. annual 90-minute test.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/14/2024

1.Emergency light 30 second testing completed on 3/26/2024. Emergency light annual 90 minutes test was completed on 10/6/2023.
2.NHA/Designee will in-service maintenance department on requirements for completing a monthly 30-second test and an annual 90-minutre test on battery back-up lighting.
3.Director of maintenance/ designee will complete audit for monthly testing X 3 to ensure completion and documentation of 30 second testing. NHA will monitor the annual test completion x1 annually.
4.Results of audit to be reported at QAPI.

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting two of three levels.

Findings include:

Observation on March 25, 2024, revealed the following deficiencies of hazardous area enclosures:

a. 11:00 a.m., on the first floor, main dining room door failed to self-close and latch. Room is used for storage.
b. 12:05 p.m., basement housekeeping storage #8 door had open hole below the handle.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the hazardous area deficiencies.




 Plan of Correction - To be completed: 05/14/2024

1.The first floor, main dining room door has been repaired to self-close and positively latch. The hole under the handle in the basement housekeeping storage #8 door has been covered.
2.NHA/Designee will in-service maintenance department on ensuring facility doors positively latch and self-close.
3.Director of maintenance/ designer will complete random audits of fire-resistant doors to ensure they positively latch weekly x 2, then monthly x 2.
4.Results of audit to be reported at QAPI.

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 document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting one of three levels.

Findings include:

Document review on March 25, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing the following kitchen components had been serviced as required:

a. 1- semi-annual kitchen suppression system inspection.
b. 1- semi-annual kitchen hood cleaning.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/14/2024

1.Kitchen suppression testing was completed on 2/27/2024. The testing is automatically scheduled with contracted services. Kitchen hood cleaning was completed on 4/25/2023, 8/31/2023, 11/7/2023. Next one is scheduled to be done on 4/12/2024.
2.NHA/Designee will educate the dietary and maintenance managers on required semi-annual testing of the kitchen suppression system, and the required semi-annual kitchen hood cleaning.
3.NHA/designee will audit facility inspection binder monthly x2 to assure reports are secured after work has been completed.
4.Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

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

Findings include:

Document review on March 25, 2024, at 9:30 a.m., revealed the June 7, 2023, Fire alarm inspection listed the following deficiency: FACP is not functioning properly. Inspection cannot be completed because we have lost control of the FACP. This panel is no longer supported. Devices are obsolete. FACP needs to be replaced. Facility is on Fire Watch. Corrective action was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the Fire Alarm System deficiency.




 Plan of Correction - To be completed: 05/14/2024

1.The fire panel has been restored and is functioning properly.
2.The fire alarm inspection has been completed by the facility's fire safety vendor. NHA/Designee will educate the maintenance director on the requirements for completing the required fire alarm inspections.
3.NHA/designee will audit facility inspection binder monthly x2 to assure reports are secured after work has been completed.
4.Report of Audit will be reported in QAPI meeting.

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 - Component: 01 - Tag: 0353

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

Findings include:

Observations on March 25, 2024, revealed the following sprinkler system deficiencies:

a. 11:15 a.m., in the basement, laundry washer room, missing escutcheon.
b. 11:30 a.m., on the first floor, Physical Therapy closed sprinkler obstructed by light fixture.
c. 12:10 p.m., Chapel Choir Loft, sprinkler recessed into ceiling.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the sprinkler deficiencies.




 Plan of Correction - To be completed: 05/14/2024

1.The laundry washer room escutcheon is replaced, PT gym closet large light fixture removed, chapel choir loft sprinkler fixed on the ceiling.
2.NHA/Designee to in-service maintenance staff to ensure facility maintains automatic sprinkler system components.
3.The maintenance director/designee will audit the sprinkler heads weekly x 2 and then monthly x 2 to ensure they are properly maintained.
4.Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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 ensure that corridor doors were maintained to resist the passage of smoke, affecting one of three levels.

Findings include:

Observation on March 25, 2024, at 12:25 p.m., revealed, on the first floor, 500-unit clean utility corridor door failed to close and latch when tested, due to latch stuffed with paper.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the corridor door failed to latch.




 Plan of Correction - To be completed: 05/14/2024

1.The clean utility door is fixed and latching properly.
2.Nursing staff in-serviced not to stuff the latch with any material that will impede the door from closing.
3.The Don/Designee will complete a random audit to ensure facility doors are not impeded with any materials and that they positively latch weekly x 2 and then monthly x2 compliance.
4.Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation, document review and interview, it was determined the facility failed to maintain smoke compartments within required square footages, affecting three of nine smoke compartments.

Findings Include:

Observation and document review on March 25, 2024, between 8:30 a.m. and 1:30 p.m., revealed smoke compartments one, two, and five exceed the maximum allowance of 22,500 square feet in total area. Smoke compartment one included Katharine, Drexel, and St. Anthony Avenue (300 & 400 Wings). Smoke compartment two included St. Elizabeth's Garden and All Saints Boulevard (500 & 600 Wings). Smoke compartment five contained the Chapel and Administration offices (Non-Patient Care Area).

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed smoke compartments exceeded the maximum allowance.




 Plan of Correction - To be completed: 05/14/2024

1.It is the policy of the facility to ensure the smoke barriers are to provide at least two smoke compartments on every sleeping floor with a 30 or more-patient bed capacity.
2.Size of the compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any one point in the compartment to a door in the smoke carrier.
3.Smoke Compartment One (300 and 400 wings)
4.Smoke Compartment Two (500 and 600 wings)
5.Smoke Compartment Five (Chapel and Administration)
6.The facility request that the required FSES worksheet to be completed by the Department of Health in accordance with NAPA 101A.

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




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

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

Findings include:

Observation on March 25, 2024, at 12:45 p.m., revealed, on the first floor, in multi-purpose room kitchen, a non-GFCI outlet within six feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within six ft of the outside edge of the sink.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing GFCI outlet.




 Plan of Correction - To be completed: 05/14/2024

1.The outlet closer to the sink is closed with a cover plate.
2.NHA/Designee will educate the Maintenance Director on ensuring the electrical wiring and equipment complies with NFPA 90, National Electric Code
3.Maintenance Director/Designee will complete a random audit of outlets to ensure they comply with NFPA Electrical Code weekly x2 and then monthly x2
4.Report of audit will be reported at QAPI

NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform one of twelve required fire drills.

Findings include:

Document review on March 25, 2024, at 9:30 a.m., revealed the facility could not provide documentation that a fire drill was conducted, third shift, second quarter.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/14/2024

1.The facility was aware of the missed shift of the drill and noted 2 drills on the same shift in a quarter were completed. A PIP was initiated and the NHA monitored the process and assured fire drills were completed in the required manner and reported in QAPI.
2.Fire drills have been contracted to be completed by outside company from the PIP. A schedule will be created to ensure the facility does not miss any required fire drills.
3.NHA/designee will audit fire drills monthly x3 to ensure compliance with the twelve annual, required fire drills.
4.Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to conduct annual fire door inspections, for one of one required inspection.

Findings include:

Document review on March 25, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing that an annual fire door inspection was performed.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/14/2024

1.Annual fire door inspection was completed on 4/10/2024.
2.NHA/Designee will educate the maintenance director on the requirements for completing an annual fire door inspection. Annual fire door inspection is placed on TELS to be completed every year.
3.The maintenance director designee will monitor completion annually.
4.Report of completion will be reported in QAPI meeting annually.

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 - Component: 01 - Tag: 0911

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

Findings include:

Observations on March 25, 2024, revealed the following electrical deficiencies:

a. 11:45 a.m., on the first floor, room 308, PTAC unit cover was removed, exposing the inner wiring.
b. 12:20 p.m., on the first floor, 700 Nurse Station, electrical panel PP2 missing a protective blank.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the electrical deficiencies.

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




 Plan of Correction - To be completed: 05/14/2024

1.Room 308 PTAC cover was replaced and is properly fitted. 700 unit PP2 electrical panel missing plate was replaced with cover.
2.NHA/Designee to educate maintenance staff on ensuring that there is protection of electrical wiring for electrical wiring within the facility.
3.Maintenance director/ designee will complete a random audit of resident PTACs and electrical panels to ensure the electrical wiring is protected weekly x 2 and then monthly x2.
4.Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations within this facility.

Findings include:

Document review on March 25, 2024, at 9:00 a.m., revealed the facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the previous 12 months.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 05/14/2024

1.Annual receptacle testing has been completed.
2.NHA/Designee will educate the Maintenance Director of the requirements of completing an annual receptacle testing at patient bed locations. Annual testing of receptacles at bed locations is placed on TELS for completion.
3.The maintenance director will monitor the completion of tasks annually and report to NHA.
4.Report of completion will be reported in QAPI meeting annually.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator.

Findings Include:

Document review on March 25, 2024, at 9:30 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a. monthly testing of battery electrolyte specific gravity or conductance testing.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/14/2024

1.The testing of the battery of the generator is completed.
2.Monthly testing of the battery is placed on TELS. NHA/Designee to educate the maintenance staff on the requirements for the monthly testing generator testing.
3.The maintenance director/designee will audit battery testing monthly X3
4.Report of completion will be reported in QAPI meeting annually.

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 - 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 three levels.

Findings include:

Observations on March 25, 2024, revealed the following electrical deficiencies:

a. 12:05 p.m.. on the second floor, kitchen, surge protector mounted next to the sink.
b. 11:15 a.m., on the second floor, kitchen, extension cord in use at time of survey.
c. 12:25 p.m., on the first floor, 500 Nurse supervisor office, fridge plugged into surge protector.

Exit Interview with the Administrator and Maintenance Director on March 25, 2024, at 1:45 p.m., confirmed the unauthorized electrical devices.




 Plan of Correction - To be completed: 05/14/2024

1.2nd floor Kitchen surge protector was removed from next to sink. 2nd floor extension cord was removed from common area. 500 Nurse supervisor office fridge plug removed from extension cord and plugged into the wall unit.
2.NHA/Designee to complete a facility-wide education on the prohibition of unauthorized use of electrical devices.
3.Maintenance director/designee will complete a random audit of offices, nursing stations, and/or common areas to ensure there are no unauthorized uses of electrical devices. weekly x2 and monthly x2.
4.Report of completion will be reported in QAPI meeting annually.


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