Pennsylvania Department of Health
LECOM AT ELMWOOD GARDENS, LLC
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LECOM AT ELMWOOD GARDENS, LLC
Inspection Results For:

There are  49 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.
LECOM AT ELMWOOD GARDENS, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on April 11, 2024, at Lecom at Elmwood Gardens, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID #680202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 11, 2024, it was determined that Lecom at Elmwood Gardens 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 III (200), unprotected, ordinary building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

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

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

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

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

Based on observation and interview, the facility failed to maintain construction type and height regulations of all building areas.

Findings include:

Observation on April 11, 2024, at 12:00 p.m., revealed the facility exceeded the height requirement for a Type III (200) building construction.

Interview with the director of facilities on April 11, 2024, at 12:00 p.m., confirmed the facility exceeded the height requirements for the listed construction type.



 Plan of Correction - To be completed: 04/24/2024

FSES grandfathered in the same as last year. Every area of all three levels is fully covered by sprinklers and an automatic system. Documentation can be provided.
NFPA 101 STANDARD Egress Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, the facility failed to meet egress door requirements in one of over five egress passageways.

Findings include:

Observation on April 11, 2024, at 9:30 a.m., revealed the east hallway, near room 8, had an exit door that was difficult to open without significant force.

Interview with the maintenance supervisor on April 11, 2024, at 9:30 a.m., confirmed the deficiency at the time of the survey.




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

Maintenance Director and team repaired door on April 23rd, 2024.

Maintenance Director and team educated on proper inspection/testing of door function.

Annual binders are created which include a separate page for each door. Maintenance Director and his team use these for routine door inspections.

Monthly testing will be completed and documented to ensure proper function.

NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to meet emergency lighting maintenance and testing requirements for four of four emergency lights.

Findings include:

Observation on April 11, 2024, at 8:55 a.m., revealed the facility failed to provide documentation for the following emergency lighting requirements:
A. (8:55 a.m.) 30-second monthly testing;
B. (8:55 a.m.) Annual 90-minute testing.

Interview with the maintenance supervisor on April 11, 2024, at 8:55 a.m., confirmed the deficiency at the time of the survey.




 Plan of Correction - To be completed: 04/24/2024

30-second testing of emergency lighting was completed on April 12th, 2024.

Maintenance Director educated on emergency lighting testing requirements.

Maintenance Director will keep proper documentation on 30-second monthly and 90-minute annual testing.

Audits will be completed by Nursing Home Administrator monthly to ensure proper compliance is being met with 30-second monthly testing and 90-minute annual testing.

Nursing Home Administrator will meet with Maintenance Director to monitor and review on a quarterly basis.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




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

Based on document review and interview, the facility failed to meet two of two cleaning requirements for the kitchen hood/duct.

Findings include:

Observation on April 11, 2024, at 8:42 a.m., revealed the last documented kitchen hood duct cleaning was completed in January 2023. The facility failed to provide semi-annual kitchen hood/duct cleaning documentation at the time of the survey.

Interview with the maintenance supervisor on April 11, 2024, at 8:42 a.m., confirmed the deficiency.



 Plan of Correction - To be completed: 05/20/2024

Summit Fire and Security performed the hood cleaning on April 25th, 2024. Documentation will be provided to Life Safety via email.

LECOM at Elmwood Gardens is now on a semi-annual inspection schedule with Summit Fire and Security.

Maintenance Director has scheduled dates for these inspections to ensure compliance.

Maintenance Director will complete quarterly audits to ensure compliance.

Results of these audits will be reviewed at the quality assurance meeting.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, the facility failed to maintain the proper fire resistance rating for a smoke barrier construction, affecting all smoke compartments.

Findings include:

Observation on April 11, 2024, at 9:45 a.m., revealed the facility had an FSES for incomplete smoke barriers.

Interview with the maintenance supervisor on April 11, 2024, at 9:45 a.m., confirmed the building had an FSES.



 Plan of Correction - To be completed: 05/10/2024

This is evidenced by the approval letter dated August 21, 2021 signed by Charles Schlegel. Documentation will be submitted via email to Life Safety.

The project timeframe was extended due to a delay in receiving the doors and getting worked into contractor's schedule.

The Drawing Index # is H-21-0920.

Inspection of completion and occupancy were requested in December of 2022.

A Life Safety inspector inspected construction in early 2023.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 01 - Component: 01 - Tag: 0374

Based on observation and interview, the facility failed to meet smoke barrier door requirements for one of over five smoke barrier doors.

Findings include:

Observation on April 11, 2024, at 10:44 a.m., revealed the smoke barrier door near room 26 failed to positively latch in the frame.

Interview with the maintenance supervisor on April 11, 2024, at 10:44 a.m., confirmed the deficiency at the time of the survey.



 Plan of Correction - To be completed: 05/10/2024

Smoke barrier door near room 26 was repaired and now properly latches.

Maintenance Director and team were educated on proper function of smoke doors and requirements. Documentation will be submitted via email.

Annual binders are created which include a separate page for each door.

The Maintenance Director and his team use these for routine door inspections.

Maintenance will perform and document monthly inspections to ensure this does not become an issue in the future.



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

Based on document review and interview, the facility failed to meet door maintenance and testing requirements for two of two building components.

Findings include:

Observation on April 11, 2024, at 8:20 a.m., revealed the fire/smoke door inspection, completed March 15, 2024, did not include doors 39-81.

Interview with the maintenance supervisor on April 11, 2024, at 8:20 a.m., confirmed the deficiency at the time of the survey.



 Plan of Correction - To be completed: 05/20/2024

Maintenance Director and team were educated on annual fire door inspection requirements. Documentation will be submitted via email.

Annual binders were created which include a separate page for each door.

The Maintenance Director and his team use these for routine door inspections.

The annual inspection was started on February 15th, 2024 - 39 out of 81 doors were completed, the balance did not meet the deadline of March 23 when the previous year was completed.

The Maintenance Director has set a completion date and will monitor, monthly audits will occur until completed.

Results of these audits will be reviewed at the monthly quality assurance meeting.


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

Based on document review and interview, the facility failed to meet maintenance and testing requirements for one of one essential electrical system.

Findings include:

Observation on April 11, 2024, between 9:02 a.m. and 9:05 a.m., revealed the facility failed to provide documentation for the following generator requirements:
A. (9:02 a.m.) Monthly conductance testing;
B. (9:03 a.m.) Annual fuel quality analysis;
C. (9:05 a.m.) Three-year, four-hour load test.

Interview with the maintenance supervisor on April 11, 2024, at 9:05 a.m., confirmed the deficiencies at the time of the survey.




 Plan of Correction - To be completed: 05/30/2024

Maintenance Director and team were educated on the monthly generator checks, annual fuel quality and four-hour load test. More education and training will be completed with a representative from Cleveland Brothers in early May.

With the recent transition of ownership to LECOM, Elmwood Gardens is in the process of securing a contract with a new vendor, Cleveland Brothers who will complete the required annual 4-hour load test and annual fuel testing.

We are currently scheduled to have our 4-hour load test and fuel inspection on May 16th, 2024. Proper documentation will be supplied to Life Safety upon completion of these tests.

Monthly inspections will be completed by Maintenance department.

Maintenance Director will audit on a monthly basis to ensure compliance.

Results of this audit will be reviewed at the monthly quality assurance meeting.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to meet electrical equipment requirements for one of two building components.

Findings include:

Observation on April 11, 2024, at 11:48 a.m., revealed the salon area had two six-to-one outlet multipliers screwed into the receptacle with appliances being powered.

Interview with the maintenance supervisor on April 11, 2024, at 11:48 a.m., confirmed the deficiency at the time of the survey.



 Plan of Correction - To be completed: 05/20/2024

The outlets were removed while inspector was still in the facility completing the inspection.

It was discovered the outlets were installed by the beautician without approval from the Maintenance department or facility.

Education was provided to the beautician as well as the Maintenance department.

Maintenance will perform and document monthly inspections to ensure compliance.

Maintenance Director will perform monthly audits.

Results of these audits will be reviewed at monthly compliance meeting.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #680202
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on April 11, 2024, it was determined that Lecom at Elmwood Gardens was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0291

Based on document review and interview, the facility failed to meet emergency lighting maintenance and testing requirements for four of four emergency lights.

Findings include:

Observation on April 11, 2024, at 8:55 a.m., revealed the facility failed to provide documentation for the following emergency lighting requirements:
A. (8:55 a.m.) 30-second monthly testing;
B. (8:55 a.m.) Annual 90-minute testing.

Interview with the maintenance supervisor on April 11, 2024, at 8:55 a.m., confirmed the deficiencies at the time of the survey.




 Plan of Correction - To be completed: 04/24/2024

30-second testing of emergency lighting was completed on April 12th, 2024.

Maintenance Director educated on emergency lighting testing requirements.

Maintenance Director will keep proper documentation on 30-second monthly and 90-minute annual testing.

Audits will be completed by Nursing Home Administrator monthly to ensure proper compliance is being met with 30-second monthly testing and 90-minute annual testing.

Nursing Home Administrator will meet with Maintenance Director to monitor and review on a quarterly basis.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0372

Based on observation and interview, the facility failed to maintain the proper fire resistance rating for a smoke barrier construction, affecting all smoke compartments.

Findings include:

Observation on April 11, 2024, at 9:45 a.m., revealed the facility had an FSES for incomplete smoke barriers.

Interview with the maintenance supervisor on April 11, 2024, at 9:45 a.m., confirmed the building had an FSES.



 Plan of Correction - To be completed: 05/20/2024

This is evidenced by the approval letter dated August 21, 2021 signed by Charles Schlegel. Documentation will be submitted via email to Life Safety.

The project timeframe was extended due to a delay in receiving the doors and getting worked into contractor's schedule.

The Drawing Index # is H-21-0920.

Inspection of completion and occupancy were requested in December of 2022.

A Life Safety inspector inspected construction in early 2023.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0761

Based on document review and interview, the facility failed to meet door maintenance and testing requirements for two of two building components.

Findings include:

Observation on April 11, 2024, at 8:20 a.m., revealed the fire/smoke door inspection, completed March 15, 2024, did not include doors 39-81.

Interview with the maintenance supervisor on April 11, 2024, at 8:20 a.m., confirmed the deficiency at the time of the survey.



 Plan of Correction - To be completed: 05/20/2024

Maintenance Director and team were educated on annual fire door inspection requirements.

Documentation will be submitted via email.

Annual binders were created which include a separate page for each door.

The Maintenance Director and his team use these for routine door inspections.

The annual inspection was started on February 15th, 2024 - 39 out of 81 doors were completed, the balance did not meet the deadline of March 23 when the previous year was completed.

The Maintenance Director has set a completion date and will monitor, monthly audits will occur until completed.

Results of these audits will be reviewed at the monthly quality assurance meeting.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to meet maintenance and testing requirements for one of one essential electrical system.

Findings include:

Observation on April 11, 2024, between 9:02 a.m. and 9:05 a.m., revealed the facility failed to provide documentation for the following generator requirements:
A. (9:02 a.m.) Monthly conductance testing;
B. (9:03 a.m.) Annual fuel quality analysis;
C. (9:05 a.m.) Three-year, four-hour load test.

Interview with the maintenance supervisor on April 11, 2024, at 9:05 a.m., confirmed the deficiency at the time of the survey.



 Plan of Correction - To be completed: 05/30/2024

Maintenance Director and team were educated on the monthly generator checks, annual fuel quality and four-hour load test. More education and training will be completed with a representative from Cleveland Brothers in early May.

With the recent transition of ownership to LECOM, Elmwood Gardens is in the process of securing a contract with a new vendor, Cleveland Brothers who will complete the required annual 4-hour load test and annual fuel testing.

We are currently scheduled to have our 4-hour load test and fuel inspection on May 16th, 2024. Proper documentation will be supplied to Life Safety upon completion of these tests.

Monthly inspections will be completed by Maintenance department.

Maintenance Director will audit on a monthly basis to ensure compliance.

Results of this audit will be reviewed at the monthly quality assurance meeting.

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