Pennsylvania Department of Health
ACCELA REHAB AND CARE CENTER AT SPRINGFIELD
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 40 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.


ACCELA REHAB AND CARE CENTER AT SPRINGFIELD - 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 May 13, 2024, it was determined that Accela Rehab And Care Center At Springfield had deficiencies that have potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:

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(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility.

Findings include:

Document review on May 13, 2024, at 9:45 a.m., revealed the facility failed to provide documentation of the role of the facility under a waiver declared by the Secretary of the Department of Health.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 2:15 p.m., confirmed the lack of required documentation inside the Emergency Prepardness Plan.

Plan of Correction - To be completed: 07/04/2024

The facility failed will develop an Emergency Preparedness Plan to include the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility.

Re- education regarding the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility will be conducted by the Maintenance Directordesignee

An audit of the Emergency Prep manual will be conducted weekly to ensure that the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility is included

The findings of the audit will be brought to Quality improvement committee monthly for three months and quarterly therafter

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

Facility ID# 580502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2024, it was determined that Accela Rehab And Care Center At Springfield - Main Building 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 three-story, Type III (200), unprotected, ordinary building, with basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0100

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

Findings Include:

Documentation reviewed on May 13, 2024, at 10:00 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction provide a portable, accurate floor plan on site to be used during the Life Safety Code Survey.

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

In addition to the above, the following information is required on the portable floor plans for facilities utilizing the Fire Safety Evaluation System (FSES):
dimensions (length and width)
Room numbers and number of residents in each room
station locations to include # of nurses at each location
arrows for emergency movement routes
room use must be identified (dining, soiled linen, housekeeping, office, etc.)
where FSES deficiency exists on floor plans.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 2:15 p.m., confirmed the lack of required life safety floor plans for Building.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain portable floor plans outlining designated rated partitions, affecting the entire facility. in the Emergency Prep Manual

Re- education regarding the need to maintain portable floor plans outlining designated rated partitions, affecting the entire facility. in the Emergency Prep Manual will be conducted by the Maint Dir

A weekly audit ensuring that the center is maintaining portable floor plans outlining designated rated partitions, affecting the entire facility. in the Emergency Prep Manual By Maintenance Director/Designee

The findings of the audit will be brought to Quality Improvment Committee monthly for three months and Quarterly thereafter

NFPA 101 STANDARD Building Construction Type and Height:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0161

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

Findings include:

Observation on May 13, 2024, at 8:15 a.m., revealed this building component has been classified as a three story, Type III (200), unprotected ordinary construction, with a basement, which is fully sprinklered. The building height exceeds the maximum allowable story height for unprotected ordinary construction by two stories.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed minimum building construction requirements were not maintained.

Plan of Correction - To be completed: 07/04/2024

The facility respectfully requests DOH Life Safety to perform a new FSES and if the building does not pass or makes other corrections to satisfy the FSES the facility will ask for a time limited waiver to correct the concern.

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

NFPA 101 STANDARD Means of Egress - General:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0211

Based on observation, document review and interview, it was determined the facility failed to maintain the means of egress without obstructions, affecting 3 of five smoke compartments.

Findings include:

1. Documentation reviewed and observation made on May 13, 2024 at 10:30 am, revealed headroom height in the following areas were less than 6' feet 8" inches:

a. Basement, corridor by the maintenance shop;
b. Third Floor, corridor by the stair tower.

Exit Interview with the Facility Administrator and Director of Maintenance on May 13, 2024, at 1:15 p.m, confirmed the minimum headroom clearance was not maintained.
.

Plan of Correction - To be completed: 07/04/2024

In reference headroom height in the areas were less than 6' feet 8" inches to The facility respectfully requests DOH Life Safety to perform a new FSES and if the building does not pass or makes other corrections to satisfy the FSES the facility will ask for a time limited waiver to correct the concern.

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain Special Locking Arrangements on egress doors, affecting one of four levels.

Findings include:

Observation on May 13, 2024, at 12:22 p.m., on the second floor (Main), revealed fire escape stair door #206, was equipped with a delayed egress feature. The door lacked required signage stating, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.

Exit Interview with the Facility Administrator and Director of Maintenance, on May 13, 2024, at 1:15 p.m., confirmed the required signage was not installed.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain Special Locking Arrangements on egress doors, affecting the following areas

The second floor (Main), fire escape stair door #206, that equipped with a delayed egress feature now has the signage stating, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.

Re- education regarding the Need for signage on egress doors with Special locking arrangements will be conducted to facility staff by Maintenance Director/designee

An audit of the signage will be completed weekly by the Maintenance Director to ensure that the signage is posted and present

The findings of the audit will be brought to Quality improvement committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:

Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0232

Based on observation and interview, it was determined the facility failed to maintain required corridor widths, affecting one of five smoke compartments within this component.

Findings include:

Observation on May 13, 2024, between 10:00 a.m. and 2:15 p.m., revealed corridor widths, in several locations on the First Floor, were less than the minimum requirement of 48" inches.

Exit Interview with the Facility Administrator and Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the minimum corridor widths were not maintained.

Plan of Correction - To be completed: 07/04/2024

The facility respectfully requests DOH Life Safety to perform a new FSES and if the building does not pass or makes other corrections to satisfy the FSES the facility will ask for a time limited waiver to correct the concern.
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

NFPA 101 STANDARD Emergency Lighting:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain required testing for emergency lighting, affecting entire facility.

Findings Include:

Document review on May 13, 2024, at 8:15 a.m., revealed the following deficiencies:

a. The facility could not provide documentation monthly 30 second battery check inspection for emergency lighting.
b. The facility could not produce documentation of the annual ninety minute testing of the battery back up lighting.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain required testing for emergency lighting for the entire facility by:

a. The facility maintenance staff will document monthly 30 second battery check inspection for emergency lighting.
b. The facility maintenance staff will document of the annual ninety minute testing of the battery back up lighting.

Re- education regarding the need to test for emergency lighting will be conducted by the Maintenance Director/designee

An weekly audit of the testing will be conducted by the facility Maintnance director to ensure that the documentaiton of the testing is present.

The findings of the audit will be reviewed in quality improvemnt committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Exit Signage:

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.

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

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

Based on documentation review and interview, it was determined the facility failed to maintain inspection of exit and directional signs, affecting the entire facility.

Findings include:

Document review on May 13, 2024, at 8:00 a.m., revealed the faciltiy failed to provide documentation of Exit sign monthly inspection reports prior to March 2024.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain inspection of exit and directional signs, affecting the entire facility.

The Facility Maintenance staff will document inspection of Exit sign monthly.

Re- education will be provided to maintenance staff regarding the inspection o exit and directional signs inspection

A weekly audit of the signs will be conducted by the Maintenance Dirrector to ensure that it is in place

The findings of the audit will be reviewed in Quality Improvment committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Vertical Openings - Enclosure:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0311

Based on observation, document review, and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings between floors, affecting the entire component.

Findings include:

Documentation review on May 13, 2024, at 8:15 a.m., revealed the non-used dumbwaiter shaft lacked a two-hour, fire rated enclosure. Vertical openings require a two-hour fire rating in openings greater than three stories in height.

Exit Interview with the the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the vertical enclosure was not completed.

Plan of Correction - To be completed: 07/04/2024

The facility respectfully requests DOH Life Safety to perform a new FSES and if the building does not pass or makes other corrections to satisfy the FSES the facility will ask for a time limited waiver to correct the concern.
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

NFPA 101 STANDARD Cooking Facilities:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain inspections of cooking equipment, affecting 2 of four inspections.

Findings Include:

1. Documentation reviewed on May 13th, 2024, revealed inspection and maintenance of cooking equipment documentation was not available for the following time frames:

a. the Kitchen suppression system lacked documentation of a semi-annual inspection prior to and after December 5, 2023;
b. the Kitchen exhaust hood/duct cleaning lacked documentation of a semi-annual inspection after September 21, 2023.

2. Documentation reviewed on May 13th, 2024, at 10:43 a.m., revealed the Kitchen ansul system lacked visual inspection records prior to April 2024.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13th , 2024, at 1:15 p.m., confirmed the cooking equipment had not been inspected at required intervals.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain inspections of cooking equipment, affecting 2 of four inspections.

1. Inspection and maintenance of cooking equipment documentation will be completed and available:

a. the Kitchen suppression system semi-annual inspection prior
b. the Kitchen exhaust hood/duct cleaning semi-annual inspection after September 21, 2023.

2. The Kitchen ansul system will have visual inspection completed.

Re- education regarding the required documentation for inspections of cooking equipment will be provided to maintenance staff by the Maintenance Dirrector/designee

An audit of the following:

1. Inspection and maintenance of cooking equipment documentation will be completed and available:

a. the Kitchen suppression system semi-annual inspection prior
b. the Kitchen exhaust hood/duct cleaning semi-annual inspection after September 21, 2023.

2. The Kitchen ansul system will have visual inspection completed.
will be conducted by the Maintenance Director monthly for three months and quarterly therafter

The findings of the audits will be brought to QI committee monthly for three months and quarterly therafter

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0345

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

Findings Include:

1. Documentation reviewed on May 13, 2024, at 8:15 a.m., revealed the fire alarm report dated April 16, 2024 listed a single deficiency, "Failure of duct detector - Mech Room/ Old Building." Verification of repair was not available at the time of survey.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the fire alarm deficiency.

2. Observation on May 13, 2024, at 12:30 p.m., revealed the fire alarm panel indicated several trouble conditions.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the fire alarm panel was in trouble mode.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain fire alarm system components in operable condition, affecting the entire facility.

1. The fire alarm report dated April 16, 2024 listed a single deficiency, "Failure of duct detector - Mech Room/ Old Building." Verification of repair will be completed and available for review

2. The fire alarm panel that indicated several trouble conditions will have areas repaired and documentation will be available for review

Re-education on the need to maintain a fire alarm system that is operable condition will be provided to maintenance staff by Maintenance director/designee

An weekly audit of the fire panel will be conducted by the Maintenance director/designee to ensure that the alarm system is operable.

The findings of the audit will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Fire Alarm System - Out of Service:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0346

Based on document review and interview, it was determined the facility failed to provide fire watch policies and procedures, affecting the entire facility.
Findings include:
Document review on May 13, 2024, at 8: 15 a.m., revealed the facility could not provide fire watch policies and procedures, including time frame information on when to initiate a fire watch after the fire alarm is taken out of service.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will provide fire watch policies and procedures, affecting the entire facility.

Re- -education regarding the fire watch policies will be conducted by the Maintenance Director/designee to ensure that facility staff are aware of fire watch policies and procedures, including time frame information on when to initiate a fire watch after the fire alarm is taken out of service.

A wkly audit of the fire watch policies and procedures, will be conducted by the Maintenance direcotor/designee

The findings of the audit will be brought to quality improvement committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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

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

Based on document review, observation and interview, it was determined the facility failed to maintain automatic sprinkler systems, affecting 2 of 4 reports.

Findings include:

1. Document review on May 13, 2024, at 8:15 a.m., revealed the facility could only produce documentation of two sprinkler inspections. Records of the 1st and 4th quarters were not provided at the time of survey.

Exit Interview with the Administrator and the Facility Director on May 13, 2024, at 1:15 p.m., confirmed the lack of documentation.

2. Observation on May 13, 2024, at 12:15 p.m., revealed at Medical Supply Storage on the second floor, there were missing ceiling tiles which could delay the sprinkler activation.

Exit Interview with the Administrator and the Facility Director on May 13, 2024, at 1:15 p.m., confirmed the lack of ceiling tiles.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain automatic sprinkler systems and their documented inspections

Re- education on maintaining automatic sprinkler systems inspections and documentations will be conducted to maintnenance staff by maintenance director/designee

An weekly audit of the documentation for the sprinkler inspections will be provided by the Maintenance Director/designee

The fingings of the audits will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Sprinkler System - Out of Service:

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0354

Based on document review and interview, it was determined the facility failed to provide fire watch policies and procedures, affecting the entire facility.
Findings include:
Document review on May 13, 2024, at 8:15 a.m., revealed the facility could not provide fire watch policies and procedures, including time frame information on when to initiate a fire watch after the sprinkler system is taken out of service.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will provide fire watch policies and procedures, affecting the entire facility.

Re-education to facility staff regarding fire watch policies and procedures, including time frame information on when to initiate a fire watch after the sprinkler system is taken out of service will be conducted by the Maintenance Director/designee

An weekly audit of the fire watch policies and procedures, including time frame information on when to initiate a fire watch after the sprinkler system is taken out of service will be conducted by the Maintenance Director/designee

The findings of the audit will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0355

Based on observation, document review and interview, it was determined the facility failed to maintain inspections for portable fire extinguishers, affecting each floor level.

Findings Include:

1. Document review on May 13, 2024, at 8:15 a.m., revealed the facility could not provide the certification for the person performing maintenance and recharging of fire extinguishers.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 2:15 p.m. confirmed the lack of documentation.

2. Observation on May 13, 2024, at 12:45 p.m., revealed the portable fire extinguisher inside the basement (Main) Telephone Room was not mounted to the wall.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 2:15 p.m., confirmed the lack of fire extinguisher mounting.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain inspections for portable fire extinguishers, affecting each floor level and a certification for the person performing maintenance and recharging of fire extinguishers will be available for review

Re-eduction regarding inspections for portable fire extinguishers, affecting each floor level and a certification for the person performing maintenance and recharging of fire extinguishers will be available for review by the Maintenance Director/designee

A weekly audit of the inspections for portable fire extinguishers, affecting each floor level and a certification for the person performing maintenance and recharging of fire extinguishers will be available for review by the Maintenance Director/designee

The findings of the audit will be brought ot QI committee monhthly for three months and quarterly thereafter

NFPA 101 STANDARD HVAC:

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

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

Based on document review and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning (HVAC) system, affecting the 4 of 20 dampers.

Findings include:

Document review on May 13, 2024, at 8:15 a.m., revealed the Fire/Smoke Damper inspection report dated September 18, 2023 revealed four deficiencies related to damper obstructions. No documentation provided at the time of survey showing corrective action of the deficiencies.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of corrective action documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will be free of damper obstructions in the heating, ventilating and air conditioning (HVAC) system,with corresponding documentation of the inspection

Re-education regarding free of damper obstructions in the heating, ventilating and air conditioning (HVAC) system,with corresponding documentation of the inspection will be conducted by the Maintenance Director/designee

An weekly audit of the documentation regarding free of damper obstructions in the heating, ventilating and air conditioning (HVAC) system,with corresponding documentation of the inspection will be completed by the Maintenance Director/ designee

The findings of the audit will be brought ot QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Fire Drills:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct fire drills once per shift per quarter, affecting the entire facility.

Finding Include:

Document review on May 13, 2024, at 8:15 a.m., revealed the facility could not produce documentation of monthly fire drills.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will conduct fire drills once per shift per quarter, affecting the entire facility.

Re-education regarding fire drills must be conducted once per shift per quarter, affecting the entire facility

A weekly audit of the fire drills will be completed by the Maintenance Director/designee

The fidngs of the audit will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to conduct a required annual inspection of fire doors, affecting the entire facility.

Findings include:

Document review on May 13, 2024, at 8:15 a.m., revealed the facility failed to provide documentation of annual inspection of fire door assemblies.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 2:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/04/2024

The facility will conduct a required annual inspection of fire doors, affecting the entire facility.

Re-eduation regarding the annual inspection of fire doors, affecting the entire facility will be conducted by the maintenance director to maintenance staff

a Weekly audit of the annual inspection of fire doors, affecting the entire facility will be conducted by the Maintenance Director/designee

The findings of the audit will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Electrical Systems - Other:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to comply with NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment, affecting 1 of 4 levels in the facility.

Findings include:

Observation on May 13, 2024, at 12:25 p.m., revealed on the second floor, the electrical panel across from the Linen Closet had a missing load center filler plate exposing inner panel wiring.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the missing load center filler plate.

Plan of Correction - To be completed: 07/04/2024

The facility will comply with NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment, affecting 1 of 4 levels in the facility

The second floor, the electrical panel across from the Linen Closet exposing inner panel wiring has been closed to revent wiring from exposing by the Maintenance Director/designee

An weekly audit of the The second floor, the electrical panel across from the Linen Closet exposing inner panel will be conducted by the Maintenance Director./designee

The findings of the audit will be brought to QI committee monthly for ro three months and quarterly thereafter

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to provide proper protection for electrical equipment, affecting one of four levels in the component.

Findings include:

Observation on May 13, 2024, at 12:25 p.m., revealed on second floor, a missing outlet cover next to resident room M102.

Exit Interview with the the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the missing receptacle cover.

Plan of Correction - To be completed: 07/04/2024

The facility will provide proper protection for electrical equipment, affecting one of four levels in the component.

The second floor, a missing outlet cover next to resident room M102 has been replaced by the Maintenance Director/designee

Re-educton regarding proper protection for electrical will be provided to facility staff by Maintenance Director/designee

A weekly audit of the The second floor, a missing outlet cover next to resident room M102 has been replaced by the Maintenance Director/designee

The findings of the audit will be brought to QI committee monthly for three months and quarterly thereafter

Initial comments:Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0000

Facility ID# 580502
Component 02
Pavilion Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2024, it was determined that Accela Rehab And Care Center At Springfield - Pavilion Building, 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain exit stair tower enclosures free of unsealed penetrations, affecting one of two stair towers in this component.

Findings include:

Observations on May 13, 2024, between 10:26 a.m. and 1:10 p.m., revealed the following deficiencies

a. 10:26 a.m., West emergency stairtower had electrical penetrations not sealed in the stair wall above ceiling grid;

b. 1:10 p.m., Stairwell across P136 had electrical penetrations not sealed in the stair wall above ceiling grid.

Exit interview with the Facility Administrator and Maintenance, on May 13, 2024, at 1:15 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/04/2024

The facility has sealed penetrations, affecting the following areas:

a. West emergency stair tower has had the electrical penetrations sealed in the stair wall above ceiling grid;

b.Stairwell across P136 has had electrical penetrations sealed in the stair wall above ceiling grid.

Re- -education regarding the need to seal penetrations will be provided to maintenance staff by the Maintenance Director

a weekly audit of sealed penetrations in:
a. West emergency stair tower has had the electrical penetrations sealed in the stair wall above ceiling grid;

b.Stairwell across P136 has had electrical penetrations sealed in the stair wall above ceiling grid.
Will be conducted by the Maintenance Director or designee

The fidngs of the audit will be brought to QI committee monthly for three months and quarterly therafter

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous enclosures with a smoke tight resistance, in sprinklered locations, affecting one of four levels within this component.
Findings include:
Observations on May 13, 2024, between 11:49 a.m. and 12:05 p.m., revealed the following deficiencies:
a. 11:49 a.m., on the second floor, Biohazard/Soiled Linen Room door propped open. The door closure was physically broken;

b. 12:05 p.m., on the second floor, the Soiled Utility Room door was binding in the frame.

Exit Interview with the Facility Administrator and Director of Maintenance, on May 13, 2024, at 1:15 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain hazardous enclosures with a smoke tight resistance, in sprinklered locations listed:

The second floor, Biohazard/Soiled Linen Room door will be repaired

b. The second floor, the Soiled Utility Room door frame has been repaired.By the Maintenance Director

Re- education regarding maintain hazardous enclosures with a smoke tight resistance, in sprinklered locations will be conducted by the Maintenance Director/designee

A weekly audit of the following areas will be conducted to ensure compliance:
The second floor, Biohazard/Soiled Linen Room door will be repaired

b. The second floor, the Soiled Utility Room door frame has been repaired.By the Maintenance Director

The findings of the audit will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0347

Based observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of four levels in the component

Findings include:

Observation on May 13, 2024, at 11:31 a.m., revealed the smoke detector in the corridor on the second floor, outside of resident room room P236 was missing a device trim ring exposing a gap.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the lack of trim ring.

Plan of Correction - To be completed: 07/04/2024

the facility failed to maintain smoke detectors in the following areas:
a. the smoke detector in the corridor on the second floor, outside of resident room room P236 will have the device trim ring exposing a gap sealed by the Maintenance Director

Re- education regarding the need for the facility to maintain smoke detectors in the corridor of the second floor outside of resident room P236 will be provided to maintenance staff by the Maintenance Director

A weekly audit of the the smoke detector in the corridor on the second floor, outside of resident room room P236 will have the device trim ring exposing a gap sealed by the Maintenance Director

The findings of the audits will be brought to QI committee monthly for three months and quarterly thereafter.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting three of four levels in the component..

Findings include:

Observations on May 13, 2024, between 10:10 a.m. and 1:35 p.m., revealed the following sprinkler deficiencies:

a. 10:10 a.m., inside the basement mechanical room revealed a sprinkler head the above boiler, obstructed by mechanicals;
b. 10:10 a.m., inside the basement mechanical room revealed lack of sprinkler coverage behind boilers at the back wall exhaust of room;
c. 10:50 a.m., inside the kitchen revealed a missing sprinkler escutcheon located outside the walk in cooler;
d. 1:15 a.m., inside the basement sprinkler room revealed multiple missing ceiling tiles in ceiling grid that could delay the activation of the sprinkler;
e. 11:42 a.m., on the second floor, inside resident room P230 revealed a missing sprinkler escutcheon in the bathroom;
f. 1:35 p.m., on the first floor, Nurses station, missing sprinkler escutcheon above the counter area.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain automatic sprinkler system components in the following areas

a.inside the basement mechanical room
b. inside the basement mechanical room behind boilers at the back wall exhaust of room will be sprinklered;
c. inside the kitchen the sprinkler escutcheon located outside the walk in cooler will be replaced;
d. inside the basement sprinkler room r missing ceiling tiles in ceiling grid have been replaced;
e. on the second floor, inside resident room P230 will have the sprinkler escutcheon in the bathroom replaced;
f. on the first floor, Nurses station, missing sprinkler escutcheon above the counter area has been replaced

RE- education regarding maintaining automatic sprinkler systems will be conducted by the Mainttenance director/ designee to maintenance staff

A wkly audit of the following areas will be conducted by the Mainteance Director/designee:
a.inside the basement mechanical room
b. inside the basement mechanical room behind boilers at the back wall exhaust of room will be sprinklered;
c. inside the kitchen the sprinkler escutcheon located outside the walk in cooler will be replaced;
d. inside the basement sprinkler room r missing ceiling tiles in ceiling grid have been replaced;
e. on the second floor, inside resident room P230 will have the sprinkler escutcheon in the bathroom replaced;
f. on the first floor, Nurses station, missing sprinkler escutcheon above the counter area has been replaced

The findings of the audit will be reviewed in QI committee MTG monthly for three months and quarterly thereafter

NFPA 101 STANDARD Corridor - Doors:

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

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

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with a smoke tight resistance and positive latching, affecting two of four levels in the component.
Findings include:
Observations on May 13, 2024, between 10:55 a.m. and 11:25 a.m., revealed the following deficiencies:
a. 10:40 a.m., Kitchen back door from corridor is missing the door closure cover;

b. 10:55 a.m., main doors into dietary to corridor had an approimately a 1" gap around the door frame and the cinder block smoke wall;
c. 11:02 a.m., Kitchen door to seating area was missing the door closure cover;

d. 11:25 a.m., on the second floor, the door to resident room P-238 had a self-closure with a hold open feature installed not tied into the fire alarm system.

Exit Interview with the Administrator and Facility Director on May 13, 2024, at 1:15 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/04/2024

The facility will maintain corridor doors with a smoke tight resistance and positive latching,
The Kitchen back door from corridor that was missing the door closure cover now has the closure cover

Main doors into dietary to corridor had an approimately a 1" gap around the door frame and the cinder block smoke wall have been sealed

Kitchen door to seating area was missing the door closure cover now has the closure cover

The second floor, the door to resident room P-238 had a self-closure with a hold open feature installed will be tied into the fire alarm system

RE-eduation regarding maintaiing corridor doors with a smoke tight resistance and positive latching by the Mainenacne Director/designee

A wkly audit of the following areas will be conducted by the Maintenance Director designee

The fidngins of the audit will be brought to QI committee monthly for three months and quarterly thereafter

NFPA 101 STANDARD Electrical Systems - Other:

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to comply with NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment, affecting 2 of 4 levels in the facility.

Findings include:

Observations on May 13, 2024, between 10:10 a.m. and 11:54 a.m., revealed the following deficiencies:

a. 10:10 a.m., basement, Mechanical Room, water tower pump #2 controller missing the safety cover exposing 200 volt inner electrical wiring.
b. 10:42 a.m., basement, ceiling light fixture missing mounting hardware and hanging from power supply.
c. 10:48 a.m., basement, Kitchen walk-in Cooler, ceiling light fixture missing ceiling mounting hardware and hanging from power supply.
d. 11:54 a.m., on the second floor, inside Tub Room inside shower, ceiling light fixture was missing it's cover and exposing internal wiring and ballast.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the unprotected electrical components.

Plan of Correction - To be completed: 07/04/2024

The facility will with NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment,

The Mechanical Room, water tower pump #2 controller missing the safety cover exposing 200 volt inner electrical wiring now has a safety cover

The basement, ceiling light fixture missing mounting hardware and hanging from power supply now has hardware.

The Kitchen walk-in Cooler, ceiling light fixture missing ceiling mounting hardware and hanging from power supply now has hardware
The second floor, inside Tub Room inside shower, ceiling light fixture was missing it's cover now has a cover and no exposing internal wiring and ballast

Re-education regarding NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment will be conducted by the Maintenance Director/designee

a weekly audit of the following areas will be conducted:
The Mechanical Room, water tower pump #2 controller missing the safety cover exposing 200 volt inner electrical wiring now has a safety cover

The basement, ceiling light fixture missing mounting hardware and hanging from power supply now has hardware.

The Kitchen walk-in Cooler, ceiling light fixture missing ceiling mounting hardware and hanging from power supply now has hardware
The second floor, inside Tub Room inside shower, ceiling light fixture was missing it's cover now has a cover and no exposing internal wiring and ballast

The fidngs of the audit will be brought to QI committee monthly for three months and quarterly therafter

NFPA 101 STANDARD Electrical Systems - Receptacles:

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0912

Based on observation and interview, it was determined the facility failed to provide proper protection for electrical equipment, affecting one of four levels of component.

Findings include:

Observation on May 13, 2024, at 10:29 a.m., revealed in the basement medical records room, a receptacle at the entrance was a missing receptacle cover.

Exit Interview with the the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the missing receptacle cover.

Plan of Correction - To be completed: 07/04/2024

The facility will provide proper protection for electrical equipment in the facility.

The basement medical records room, areceptacle at the entrance now has a receptacle cover applied by the maintenance director

Re- education regarding protection for electrical equipment will be conducted by the Mainteance Director to medical records staff

A wkly audit of the The basement medical records room, areceptacle at the entrance now has a receptacle cover applied by the maintenance director

The fidngs of the audit will be brought ot QI committee monthly for three months and quarterly therafter

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the use of power strips, extension cords and outlet multipliers, affecting two of four levels within the component.

Findings include.

Observations on May 13, 2024, between 10:30 a.m. and 12:50 p.m., revealed the following deficiencies:

a) 10:30 a.m., on the second floor, Medical records room, extension cord used to power equipment;
b) 11:36 a.m., on the second floor, resident room P 232, extension cord used to power desk fan and power strips used for the TV;
c) 11:42 a.m., on the second floor, resident room P 234, outlet multipliers;
d) 11:45 a.m., on the second floor, resident room P 230, outlet multipliers;
e) 12:50 p.m., on the first floor, resident room P 120, extension cord.

Exit Interview with the Facility Administrator and the Director of Maintenance on May 13, 2024, at 1:15 p.m., confirmed the use of unauthorized electrical devices.

Plan of Correction - To be completed: 07/04/2024

The facility will not use the use of use of power strips, extension cords and outlet multipliers

he facility failed to prohibit the use of power strips, extension cords and outlet multipliers, affecting two of four levels within the component.

Findings include.

Observations on May 13, 2024, between 10:30 a.m. and 12:50 p.m., revealed the following deficiencies:

The second floor, Medical records room, extension cord used to power equipment have been removed

The second floor, resident room P 232, extension cord used to power desk fan and power strips used for the TV have been removed

The second floor, resident room P 234, outlet multipliers has been removed

The second floor, resident room P 230, outlet multipliers have been removed

The first floor, resident room P 120, extension cord.

Re- education regarding not using power strips, cords or outlet multipliers will be conducted to facility staff by Mainteance Director/designee

A weekly audit of the following areas will b inducted by Maintenance Director/designee:

The second floor, Medical records room, extension cord used to power equipment have been removed

The second floor, resident room P 232, extension cord used to power desk fan and power strips used for the TV have been removed

The second floor, resident room P 234, outlet multipliers has been removed

The second floor, resident room P 230, outlet multipliers have been removed

The first floor, resident room P 120, extension cord.

The findings of the audit will be brought to QI committee MTG monthly for three months and quarterly thereafter

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