Nursing Investigation Results -

Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  38 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.
VALLEY MANOR REHABILITATION AND HEALTHCARE 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 December 9, 2019, at Valley Manor Rehabilitation and Healthcare Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0000


Facility ID# 480202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification and Complaint survey conducted on December 9, 2019, it was determined that Valley Manor Rehabilitation and Healthcare Center 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 one story, Type V (000), unprotected wood frame construction, with a basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to install carbon monoxide alarms in close proximity to fossil fuel-burning devices in accordance with act 48-Care Facility Carbon monoxide Alarms Standard Act affecting the entire facility.

Findings include:

1. Observation made on December 9, 2019, at 2:20 p.m., revealed the facility failed to install carbon monoxide alarms in close proximity to fossil fuel-burning devices to be heard by staff on duty within the facility in the basement boiler room, with natural gas boilers and natural gas hot water convertors.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 pm, confirmed that carbon monoxide alarms were not installed.




 Plan of Correction - To be completed: 01/21/2020

Facility will install a carbon monoxide alarm in the basement boiler room.

Corrective Action Date: 1/21/2020

Facility staff will audit areas with fossil fuel-burning devices to ensure carbon monoxide alarms and in place.

Facility staff will audit areas with fossil fuel-burning devices to ensure carbon monoxide alarms and in place monthly x 4 months, then quarterly x 4, then as deemed necessary by the QAPI committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Means of Egress Capacity: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.
Means of Egress Capacity
The capacity of required means of egress is in accordance with 7.3.
18.2.3.1, 19.2.3.1
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0231

Based on observation and document review, it was determined the facility failed to maintain the minimum required clearances along the means of egress, affecting 1 of two levels.

Findings Include:

1. Observation and document review on December 9, 2019, between 8:30 am and 2:30 pm, revealed the basement level lacked acceptable headroom clearance along the exit access corridor. The headroom clearance was less than the required six feet, eight inches, (height was approximately six feet, six inches) from overhead sprinkler piping to finished floor level.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 pm, confirmed the headroom clearance.




 Plan of Correction - To be completed: 01/21/2020

The facility is requesting that the DOH Division of Life Safety perform an updated FSES.
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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0291

Based on document review, observation and interview, it was determined the facility failed to maintain emergency lighting, affecting one of four smoke compartments within this facility.

Findings include:

1. Document review on December 9, 2019, between 8:45 a.m. and 10:45 a.m., revealed that documentation was unavailable for the main lobby emergency back-up battery lighting fixtures monthly and annual 90 minute testing.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 pm, confirmed the documents were not available.






 Plan of Correction - To be completed: 01/21/2020

Facility conducted a 90-minute testing of the main lobby emergency back-up battery lighting fixture by 1/21/2019

Corrective Action Date: 1/21/2020

Facility will audit areas containing battery backup lighting and documentation to support that the required monthly and annual testing is completed as required.

Maintenance will review documentation monthly x 4 months, then quarterly x 4 to ensure documentation is available to support completion of the testing for emergency backup battery lighting. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined that the facility failed to ensure that the doors to hazardous areas positively latch into their frames, affecting 2 of four smoke compartments.

Findings include:

1. Observation made on December 9, 2019, between 1:20 p.m. and 2:15 p.m., revealed the following hazardous area doors failed to close completely and positively latch into their frames:

a. 1:20 p.m, 1st floor 200 wing, soiled utility room corridor door across from room 207;
b. 2:15 p.m., basement resident storage room door.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 pm, confirmed the doors failed to latch.






 Plan of Correction - To be completed: 01/21/2020

The 1st floor 200 wing soiled utility room corridor door across form 207 and the basement resident storage room door self-closing hardware has been readjusted to positively latch into the frame.

Corrective Action Date: 1/21/2020

Facility staff will check hazardous storage doors to ensure proper function.

Facility staff will audit hazardous doors weekly x 4 weeks, monthly x3 months, then as deemed necessary by the QAPI committee. All results will be reviewed by the QAPI Committee.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain inspection and equipment in operable condition of the automatic sprinkler system, affecting the entire facility.

Findings include:

1. Document review on December 9, 2019, between 8:30 a.m. am and 10:45 a.m., revealed that recorded documents verifying inspection of the automatic sprinkler system and diesel fire pump monthly churn testing were unavailable for review.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 pm, confirmed the documents were not available.






 Plan of Correction - To be completed: 01/21/2020

The fire pump is programmed to conduct an automatic churn test. The facility will document the results of this test at least monthly.
Corrective Action Date: 1/21/2020
Maintenance will maintain documentation of the fire pump churn test at least monthly.
Maintenance will review documentation monthly x 4 months, then quarterly x 4 to ensure documentation is available to support completion of the fire pump churn test. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors that positive latch and are resistive to the passage of smoke, affecting 1 of 4 smoke compartments.

Findings include:

1. Observation made on December 9, 2019, between 1:40 p.m. and 1:50 p.m., revealed the following corridor doors failed to positively latch into their door frame when tested:

a. 1:40 p.m., 200 wing room 203;
b. 1:45 p.m., 200 wing kitchen double doors;
c. 1:50 p.m., 200 wing room 201.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 p.m., confirmed the doors failed to latch.


2. Observation made on December 9, 2019, at 1:30 p.m., revealed the staff lounge corridor door had holes due to previously removed hardware.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 p.m., confirmed the door would not resist the passage of smoke.





 Plan of Correction - To be completed: 01/21/2020

The following doors have been adjusted to ensure a positive latch: Room 203, kitchen double doors, and room 201. The holes to the staff lunge corridor door have been filled with fire rated caulk.

Corrective Action Date: 1/21/2020

Maintenance will audit doors throughout the facility to ensure proper closing and completeness.

Maintenance will audit doors throughout facility to ensure proper closure and completeness monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0371

Based on observation and document review, it was determined the facility failed to provide adequate square footage of smoke compartments, affecting 2 of four smoke compartments.

Findings include:

1. Observation and document review on December 9, 2019, between 8:30 am and 2:30 pm, revealed smoke compartments 400 wing (zone two) and the first floor (zone three), Rooms 101-111 and 101-302, had zones that exceeded 22,500 square feet.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019 at 2:30 p.m., confirmed the size of the smoke compartments were larger than the maximum square footage.





 Plan of Correction - To be completed: 01/21/2020

The facility is requesting that the DOH Division of Life Safety perform an updated FSES.
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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0541

Based on observation and interview, it was determined that the facility failed to maintain the fire resistive rating of chute access enclosures, affecting one of four smoke compartments.

Findings include
1. Observation made on December 9, 2019, at 1:03 p.m., revealed the basement laundry chute discharge room door, was blocked open by a 5 gallon chemical container.
Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019 at 2:30 p.m., confirmed that the door was impeded from closing.






 Plan of Correction - To be completed: 01/21/2020

The 5 gallon bucket was removed from blocking the basement laundry room chute discharge room door. Housekeeping/Laundry staff re-education on not impeding doors from closing.

Corrective Action Date: 1/21/2020

Facility will audit the chute access enclosure to ensure fire resistive rating is maintained and doors are not impeded from closing weekly x 4, monthly x4, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Fire Drills: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 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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct fire drills at varying times under varying conditions, affecting 12 of 12 drills within this component.

Findings include:

1. Documents reviewed on December 9, 2019, between 8:30 a.m. and 10:45 a.m., revealed the following fire drill information was unavailable for review:

a. times when the quarterly shift drills took place and facility;
b. personnel who participated in the quarterly shift drills;
c. third quarter drills for the 2nd and 3rd shifts, between July and September.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019 at 2:30 p.m., confirmed the above stated documents were not available.







 Plan of Correction - To be completed: 01/21/2020

Facility will use a document to record the completion of the required monthly fire drills at varying times under varying conditions to include times when the drills took place, sign in sheets of who participated in the drills. Facility has conducted additional fire drills on the 2nd an 3rd shift.

Corrective Action Date: 1/21/2020

Maintenance will create a schedule of fire drills monthly, to ensure drills are documented and scheduled as required.

Facility will conduct an audit of fire drill documentation for required completion and required reporting requirements monthly x 4, the quarterly x4. All results will be reported to the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to complete required inspections of fire rated door assemblies, affecting the entire facility.

Findings include:

1. Document review on December 9, 2019, between 8:30 a.m. and 10:45 a.m., revealed the annual fire door inspection report indicated door failures. Verification of door repairs was not available at the time of inspection.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019 at 2:30 p.m., confirmed corrected documents of annual fire door inspection were not available.







 Plan of Correction - To be completed: 01/21/2020

Facility will audit and provide verification of the door repairs.

Maintenance staff will be educated on completing the annual inspection of fire rated doors and documenting the completion of repairs made.

Corrective Action Date: 1/21/2020

Facility will conduct audits of fire rated door inspections quarterly or as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0918

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

Findings include:

1. Document review on December 9, 2019, between 8:30 a.m. and 10:45 a.m., revealed the facility could not provide documentation confirming a 3-year, 4-hour exercise of the emergency generator had been performed.

Interview at the exit conference with the Maintenance Director and Administrator on December 9, 2019 at 2:30 p.m., confirmed the documents were unavailable.







 Plan of Correction - To be completed: 01/21/2020

Facility will complete a 3-year, 4-hour exercise of the emergency generator.

Maintenance department will be educated on needed inspections of the generator and keep a file of when the next 3-year, 4-hour exercise will need to be completed.

Corrective Action Date: 1/21/2020

Facility will audit generator testing documentation monthly x 3 months, quarterly x 3, then as deemed necessary by the QAPI Committee. All results will be reported to the QAPI Committee.


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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor electrical devices for unauthorized use, affecting one of four smoke compartments.

Findings include:

1. Observation made on December 9, 2019, at 1:52 p.m., revealed at the 1st floor 200 wing, room 205, there was a resident bed plugged into outlet multiplier.

Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019 at 2:30 p.m., confirmed the improper use of an electrical device.





 Plan of Correction - To be completed: 01/21/2020

The bed, in room 205, was plugged into the wall outlet.

Facility will re-educate staff and residents on the use of extension cords and power strips.

Corrective Action Date: 1/21/2020

Facility will conduct an audit of resident rooms to ensure compliance with the use of unauthorized electrical device use.

Maintenance will audit resident rooms for the unauthorized use of electrical devices monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.



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