Nursing Investigation Results -

Pennsylvania Department of Health
COLONIAL PARK CARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COLONIAL PARK CARE CENTER
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

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COLONIAL PARK CARE 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 September 16, 2019, at Colonial Park Care 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 - Component: 01 - Tag: 0000


Facility ID #640202
Component 01
Main Building

Based on a Medicare/Medicare Recertification Survey completed on September 16, 2019, it was determined that Colonial Park Care 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 two-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


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

Based on observation and interview, it was determined the facility failed to maintain exit egress free from obstructions, affecting one of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, at 11:08 AM revealed two wheelchairs, one lounge chair, one patient lift, one bedside table and two resident beds were stored, within the 1st floor Maintenance Exit Corridor.

Interview with the Maintenance Assistant on September 16, 2019, at 11:08 AM confirmed the obstructed exit egress.



 Plan of Correction - To be completed: 10/29/2019

The maintenance director or designee will clear the 1st floor maintenance corridor of all obstructing items to allow unobstructed egress. The maintenance director or designee will audit the exit corridor once per week for one month to assure unobstructed egress maintained. After one month, the maintenance director will inspect the exit corridor monthly and assure egress is maintained. The maintenance director will report the findings of his/her audits to the facility QAPI committee x 2 month
NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




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

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit enclosures, affecting two of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, at 11:47 AM revealed penetrations of the stairtower, above the 1st floor "A" Hall stairtower door, as evidenced by a half inch core hole and a void around two black wires.

Interview with the Maintenance Assistant on September 16, 2019, at 11:47 AM confirmed there were penetrations.




 Plan of Correction - To be completed: 10/29/2019

The maintenance director or designee has corrected the penetrations noted in the A hall stairtower and exit enclosure using 3M CP25WB Fire Barrier Sealant. The maintenance director or designee will inspect the stairtower exit enclosures for penetrations affecting smoke compartments weekly for one month to assure no new penetrations are present. After one month, the maintenance director or designee will inspect the stairtower exit enclosures monthly to assure the exit enclosures are in compliance and address as necessary. The maintenance director will report findings to the facility QAPI committee x 2 month .
NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain doors in the exit pathway to be set in motion with under 30 pounds of force, affecting two of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, at 12:01 PM revealed the exterior exit door within the stairtower, by the Main Entrance, required greater than 30 pounds of force to set the door in motion.

Interview with the Maintenance Assistant on September 16, 2019, at 12:01 PM confirmed the door did not open without excessive force.





 Plan of Correction - To be completed: 10/29/2019

The maintenance Director or designee will ensure the exterior exit door adjacent to the main entrance is replaced to allow for less than 30 pounds of force to open. Upon inspection the door requires replacing and a new door is ordered/pending replacement. The maintenance director/designee will inspect all stairtower exit doors weekly for the ability to be set in motion with less than 30 pounds of force and address as necessary. After one month, the maintenance director will inspect the stairtower exit doors monthly and report the results of the inspections to the facility QAPI meetings x 2 month.
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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to positively latch, affecting one of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, at 11:00 AM revealed the door, to the 1st floor "C" Hall Soiled Utility Room, did not positively latch within the frame.

Interview with the Maintenance Assistant on September 16, 2019, at 11:00 AM confirmed the door did not latch within the frame.





 Plan of Correction - To be completed: 10/29/2019

The maintenance director or designee will ensure the C hall soiled utility room door is repaired to meet guidelines for positive latching. The maintenance director will inspect weekly all facility doors for positive latching within the frame and make repairs as necessary to meet guidelines. After one month, the maintenance director or designee will inspect facility doors monthly and report the findings of the inspections to the facility QAPI meeting x 2 month.
NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain documentation verifying kitchen exhaust duct/hood cleanings, affecting one of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM, revealed the facility lacked documentation verifying the kitchen exhaust duct/hood had been cleaned during the six months prior to June 19, 2019.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the lack of documentation.



 Plan of Correction - To be completed: 10/29/2019

The maintenance director has requested and will provide the documentation showing kitchen exhaust hood cleaning was completed by a contracted service prior to June 19th 2019. The maintenance director will maintain records showing compliance with Cooking Facilities.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on document review, observation and interview, it was determined the facility failed to provide annual fire alarm system testing, and clear access to notification devices, affecting eight of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM revealed the facility failed to maintain verifying documentation, of a full functional fire alarm inspection, completed within the previous twelve months.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not provide documentation of the annual fire alarm test.


2. Observation on September 16, 2019, at 10:46 AM revealed the pull station, located within the 1st floor Pond View Lounge, was obstructed by a lounge chair.

Interview with the Maintenance Assistant on September 16, 2019, at 10:46 AM confirmed the obstructed pull station.





 Plan of Correction - To be completed: 10/29/2019

The maintenance director has requested and will provide documentation showing compliance with Fire Alarm System Annual Testing completed within the last 12 months. The maintenance director will maintain records showing compliance. The maintenance director or designee has corrected the obstructed pull station in the Pond View Lounge. Inservice education will be provided to facility staff on unobstructed pull stations. The maintenance director/designee will inspect fire alarm pull stations weekly for obstruction and correct as necessary. After 1 month, the maintenance director/ designee will inspect pull stations monthly for obstruction and correct as necessary to meet guidelines. The results of the inspections will be reported to the facility QAPI meetings x 2 month.
NFPA 101 STANDARD Smoke Detection: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.
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: MAIN BUILDING - Component: 01 - Tag: 0347

Based on document review and interview, it was determined the facility failed to maintain documentation verifying the sensitivity of smoke detectors, affecting eight of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM revealed the facility failed to maintain verifying documentation, of a full smoke detector sensitivity inspection completed within the previous 24 months.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not verify the smoke detector sensitivity test had been performed.





 Plan of Correction - To be completed: 10/29/2019

The maintenance director has requested and obtained documentation of compliance of smoke detector sensitivity testing within the last 24 months. The maintenance director will maintain records showing compliance with facility smoke detector sensitivity testing.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide documentation verifying the inspection and testing of the automatic sprinkler system, affecting eight of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM, revealed the facility lacked documentation verifying the automatic sprinkler system had been inspected since October 17, 2018.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the lack of documentation.



 Plan of Correction - To be completed: 10/29/2019

The maintenance director has requested and obtained documentation of the inspection and testing of the automatic sprinkler system affecting eight smoke compartments completed since October 17, 2018. The maintenance director will maintain records showing compliance with facility sprinkler inspection and testing.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide certification of the fire extinguisher technician, and documentation that the owner ' s quick checks had been performed, affecting eight of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM, revealed the facility lacked documentation verifying the certification of the inspector responsible for annual fire extinguisher inspection, completed in December 2018.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the lack of documentation.

2. Review of documentation on September 16, 2019, between 9:35 AM and 11:01 AM, revealed the owner ' s quick check of fire extinguishers had not been performed on the following extinguishers:

a. 9:35 AM, 2nd floor, Physical Therapy Room, both fire extinguishers, between January 2019 and September 2019;
b. 10:36 AM, 1st floor, Pond View, between March 2019 and May 2019;
c. 11:01 AM, 1st floor, C Hall, near Resident Room C10, between March 2019 and May 2019.

Interview with the Maintenance Assistant on September 16, 2019, at 11:01 AM confirmed the facility could not verify the owner ' s quick checks had been performed.




 Plan of Correction - To be completed: 10/29/2019

The maintenance director has requested and obtained documentation of the certification of the fire extinguisher technician inspection completed in December of 2018. The maintenance director will maintain records showing compliance with fire extinguisher technician certification. The maintenance director/designee has completed quick checks on the fire extinguishers noted in the physical Therapy room, Pond View Dining Room, and C Hall noted as absent during the life safety inspection. The maintenance director/designee will complete quick checks on all fire extinguishers located in the facility to maintain compliance. The maintenance director/designee will audit the quick checks of all fire extinguishers weekly to assure compliance. After one month, the maintenance director will quick check all fire extinguishers monthly and maintain required documentation of same ongoing. Results of the weekly audits will be reported to the facility QAPI meeting x 2 month.
NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls to be smoke tight, affecting two of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, between 10:25 AM and 11:41 AM, revealed the corridor walls were not smoke tight, at the following locations:

a. 10:25 AM, 2nd floor, F Hall, at the timeclock, around a gray wire and a telephone jack;
b. 11:41 AM, 1st floor, A Hall, at the timeclock, around a blue wire.

Interview with the Maintenance Assistant on September 16, 2019, at 11:41 AM confirmed the corridor walls were not smoke tight.




 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee has corrected the F hall corridor wall and A hall corridor wall using 3M CP25WB Fire Barrier Sealant and they are now smoke tight and compliant. The maintenance director/designee will inspect facility corridor walls for being smoke tight and address as necessary to maintain compliance. Inspections of corridor walls will be completed weekly. After one month, inspections of corridor walls will be completed monthly. Results of inspections will be reported to the facility QAPI meeting x 2 months.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the corridor doors to resist the passage of smoke, affecting one of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, at 9:46 AM revealed the undercut of the door to 2nd floor Resident Room G5 exceeded one inch.

Interview with the Maintenance Assistant on September 16, 2019, at 9:46 AM confirmed the undercut exceeded one inch.



 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee will ensure the Resident room door to G5 is corrected to be compliant with a bottom of door undercut of less than one inch. The door is in process to be replaced and a new door is ordered. The maintenance director/designee will audit all resident doors weekly for compliant undercuts. After one month, the maintenance director/designee will inspect resident doors monthly for compliance with undercuts. Results of the inspections will be reported to the facility QAPI meeting x 2 months.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors to be unobstructed from closing, and to self-close, affecting four of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, at 9:40 AM revealed the 2nd floor smoke barrier door, by Resident Room G7, was obstructed from closing by a towel cart.

Interview with the Maintenance Assistant on September 16, 2019, at 9:40 AM confirmed the smoke barrier door was obstructed.


2. Observation on September 16, 2019, at 11:20 AM revealed the 1st floor double smoke barrier doors, by Resident Room D16, each struck the door frame during their swing and did not fully close within the frame.

Interview with the Maintenance Assistant on September 16, 2019, at 11:20 AM confirmed the smoke barrier doors failed to self-close.





 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee corrected the towel cart obstructing the second floor smoke barrier door by room G7. The maintenance director/ designee will ensure the smoke barrier doors by room D16 will be repaired to meet guidelines. The maintenance director/designee will inspect the facility smoke barrier doors one time per week for one month to ensure gaps are in compliance and make any repairs as necessary. After one month, the maintenance director or designee will inspect the facility smoke barrier doors monthly to assure compliance and repair as necessary. The findings of the inspections will be reported to the facility QAPI meeting x 2 months.
NFPA 101 STANDARD Fire Drills:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to provide verifying documentation of fire drills, affecting three of the previous twelve required fire drills.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM revealed the facility lacked documentation verifying fire drills had been performed, for the following shifts:

a. 3rd Quarter of 2018, 1st Shift;
b. 3rd Quarter of 2018, 3rd Shift;
c. 2nd quarter of 2019, 3rd Shift.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not verify fire drills had been performed.




 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee will ensure fire drills are conducted as required to maintain compliance. The maintenance director / designee will perform fire drills at least quarterly on each shift at expected and unexpected times. The maintenance director will maintain required documentation of fire drills. The maintenance director/designee will audit compliance with fire drill requirements monthly x 3 months. Results of the audits will be reported to the facility QAPI meeting x 3 months.
NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain documentation verifying the electrical receptacle inspection of patient care areas had been performed, affecting eight of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM, revealed the facility lacked documentation verifying receptacles at patient bed locations had been inspected since July 2018.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not provide documentation that the inspection had been performed.



 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee will ensure that patient bed location receptacles have been inspected throughout the facility to maintain compliance. The maintenance director/designee will maintain required documentation of receptacle inspection. The maintenance director/designee will audit receptacle inspection monthly x 1 month. The maintenance director will report completion of receptacle testing to the facility QAPI meeting x 1 month.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain documentation verifying weekly visual inspections, and monthly generator testing, which serves the entire component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM, revealed the facility failed to provide documentation of generator weekly inspections, generator monthly tests, and generator battery inspections, for the previous full twelve months.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not provide documentation of the generator inspections and testing.


 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee will ensure weekly visual inspection of the generator is completed and documented to maintain compliance. The maintenance director/designee will ensure monthly tests of the generator and battery inspection is completed and the documentation maintained to prove compliance. The maintenance director/designee will audit weekly the compliance with weekly visual and monthly testing generator checks. After two months, the audit will be completed monthly. The results of the audit will be reported to the facility QAPI meeting x 2 months.
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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge protectors and extension cords, affecting one of eight smoke compartments within the component.

Findings include:

1. Observation on September 16, 2019, between 9:54 AM and 9:56 AM, revealed the following conditions, located within the 2nd floor Director of Nursing Office:

a. 9:54 AM, a surge protector supplying power to another surge protector;
b. 9:55 AM, an extension cord supplying power to a printer;
c. 9:56 AM, a surge protector supplying power to a refrigerator.

Interview with the Maintenance Assistant on September 16, 2019, at 9:56 AM confirmed the improper use of electrical devices.




 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee will ensure the improper use of the surge protectors and extension cord have been corrected in the facility Director of Nursing Office. Education will be provided to facility staff on proper use of extension cords and surge protector within the facility. The maintenance Director/designee will audit facility offices for improper use of surge protectors and extension cords weekly. After one month, the maintenance director will inspect the facility offices for improper use of surge protectors and extension cords monthly. The results of the inspections will be reported to the facility QAPI meetings x 1 months.
NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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.
Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0921

Based on document review and interview, it was determined the facility failed to provide documentation verifying battery powered emergency lighting testing, affecting eight of eight smoke compartments within the component.

Findings include:

1. Review of documentation on September 16, 2019, between 8:00 AM and 9:15 AM revealed the facility lacked documentation, verifying the following:

a. a 90-minute test of the batteries supplying power to the units, within the previous twelve months;
b. monthly visual bulb operation inspections, for the previous full twelve months.

Interview with the Maintenance Assistant on September 16, 2019, at 9:15 AM confirmed the facility could not verify the testing had occurred.




 Plan of Correction - To be completed: 10/29/2019

The maintenance director/designee will ensure that 90 minute testing is completed as required on battery powered emergency lighting. The maintenance director/designee will ensure that monthly bulb testing is completed as required on emergency lighting. The maintenance director will ensure that documentation of both are present and maintained. The maintenance director/designee will audit compliance with testing of emergency lighting battery and bulb weekly. After 1 month, the maintenance director/ designee will audit the testing of the emergency lighting battery and bulb test monthly. The results of the audits will be reported to the facility QAPI meeting x 1 month.

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