Nursing Investigation Results -

Pennsylvania Department of Health
SIEMON'S LAKEVIEW MANOR NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SIEMON'S LAKEVIEW MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  33 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.
SIEMON'S LAKEVIEW MANOR NURSING AND REHABILITATION 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 May 26, 2022, it was determined that Siemon's Lakeview Manor Nursing and Rehabilitation, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(a)(1)-(2) REQUIREMENT Plan Based on All Hazards Risk Assessment: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.
403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 460.84(a)(1)-(2), 482.15(a)(1)-(2), 483.73(a)(1)-(2), 483.475(a)(1)-(2), 484.102(a)(1)-(2), 485.68(a)(1)-(2), 485.625(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2)

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

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at 483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Name: - Component: -- - Tag: 0006
Based on document review and interview it was determined that the facility failed to provide a written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment.

Findings include:

Interview and documentation review on May 26, 2022, at 9:30 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes a facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the Facility Administrator and the Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the facility Emergency Preparedness Plan lacked a facility-based and community-based risk assessment.



 Plan of Correction - To be completed: 07/19/2022

1. The facility has an established Federal Emergency Preparedness Plan (Fed EP) that includes a facility-based and community-based risk assessment, utilizing an all-hazards approach.
2. There is only one required Federal Emergency Plan, therefore no additional reviews were needed.
3. The Executive Director educated the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73- Plan Based on All Hazards Risk Assessment specific to maintaining the Fed EP utilizing an all-hazards approach, and will continue to monitor in accordance with the standard.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and Patients: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)(1), 418.113(b)(6)(iii), 441.184(b)(1), 460.84(b)(1), 482.15(b)(1), 483.73(b)(1), 483.475(b)(1), 485.625(b)(1)

[(b) Policies and procedures. [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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015
Based on a review of the Emergency Preparedness (EP) Plan, it was determined the facilities policies and procedures failed to address all requirements of subsistence needs for staff and patients.

Findings include:

1. Interview and documentation review on May 26, 2022, at 9:30 a.m., revealed section (i) medical and pharmaceutical supplies and section (D) sewage and waste disposal requirements were not addressed in the EP Plan.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed medical and pharmaceutical supplies and sewage and waste disposal requirements were not addressed.



 Plan of Correction - To be completed: 07/19/2022

1. The facility has an established a Federal Emergency Plan with policies for the provision of medical and pharmaceutical supplies, and sewage and waste disposal requirements.
2. There is only one required Federal Emergency Plan, therefore no additional reviews were needed.
3. The Executive Director educated the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73- Subsistence Needs for Staff and Patients specific to maintaining the Fed EP with policies that provide for medical and pharmaceutical supplies, and sewage and waste disposal requirements, and will continue to monitor in accordance with the standard.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

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

Facility ID# 970202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 26, 2022, it was determined that Siemon's Lakeview Manor Nursing and Rehabilitation, 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, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100
28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the facility failed to obtain approval from the Division of Safety Inspection, Plan Review Department prior to conducting rehabilitation work in one instance, affecting entire facility.

Findings include:

1. Observation on May 26, 2022, at 11:28 a.m., revealed the facility installed a new boiler, in the boiler room and there were no state approved plans on-site.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed that plan review had not been contacted prior to beginning the rehabilitation project.





 Plan of Correction - To be completed: 07/19/2022

1. The facility has a documentation on-site of state approved plans from the Department of Labor and Industry for the noted boiler installation. The plans have also been submitted to the Department of Safety Inspection, and are awaiting approval.
2. There is only one boiler requiring state approval, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 General Requirements- Other specific to properly maintaining the boiler installation approval documentation, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain a continuously unobstructed path of egress to an exit door in one instance, affecting one of four compartments.

Finding included:

1. Observation on May 26, 2022, at 10:58 a.m., revealed the breezeway was being used to house miscellaneous storage, blocking the egress path to the exit door.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the obstructed egress path.




 Plan of Correction - To be completed: 07/19/2022

1. The storage noted to be blocking the path of egress to the exit door in the breezeway was removed.
2. Additional exit doors were reviewed for storage blocking the path of egress.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Means of Egress- General specific to maintaining the paths of egress to exit doors free from storage, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in three instances, affecting two of four smoke compartments.

Findings include:

1. Observation on May 26, 2022, revealed self-closing doors in the following locations had deficiencies:

a) 11:02 a.m., the A wing short hallway linen room door, would not self-close and latch in its frame when tested;
b) 11:43 a.m, the break room door would not self-close and latch in its frame when tested;
c) 12:35 p.m., the dry storage room door in the kitchen, was being help open with a unapproved hold open device (wooden wedge) and could not self close.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the above listed self-closing door deficiencies.





 Plan of Correction - To be completed: 07/19/2022

1. The A wing short hallway linen room door, and the break room door, have been repaired to properly self-close and latch. The unapproved hold open device noted on the dry storage room door in the kitchen was removed.
2. Additional doors with self-closing devices were reviewed for proper self-closing and latching, and unapproved hold open devices.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Doors with Self-losing Devices specific to maintaining doors with self-closing devices to proper function, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in three instances, affecting three of four smoke compartments.

Findings include:

1. Observation on May 26, 2022, revealed the following hazardous area enclosure deficiencies:

a) 10:51 a.m., the door to the medical records office, is not equipped with a self-closing device;
b) 11:31 a.m., the fire rated access hatch in the ceiling of the boiler room, was left open. (Interview with maintenance staff revealed that the facility was directed to leave the hatch open to gain additional intake air for the boiler, this direction was given to the facility by a Labor and Industry inspector when inspection of the new boiler was performed);
c) 11:54 a.m., the door to the staff development office is not equipped with a self closing device. The office is greater than fifty square feet in size, and is being used to house combustible storage.

Interview with the facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the hazardous area enclosure deficiencies.





 Plan of Correction - To be completed: 07/19/2022

1. Self-closing devices have been installed on the doors to the medical records and staff development offices. The hatch noted to be open in the ceiling of the boiler room was closed.
2. Additional hazard room doors were reviewed for properly installed self-closing devices. There was only one open ceiling hatch in the boiler room, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Hazardous Areas- Enclosures specific to properly maintaining self-closing devices on hazard room doors, and properly maintaining ceiling barriers, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




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

Based on observation and interview, it was determined the facility failed to maintain the kitchen hood in two instances, affecting one of four smoke compartments.

Findings include:

1. Observation on May 26, 2022, revealed the following kitchen hood deficiencies:

a) 8:53 a.m., the required semi-annual testing documentation for the kitchen suppression system, was missing for the last 18 months;
b) 12:40 p..m., there was an unsealed 3/4 inch hole in the kitchen hood, above the tilt skillet.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the cooking/kitchen hood deficiencies.







 Plan of Correction - To be completed: 07/19/2022

1. Documentation of the required semi-annual kitchen hood suppression system inspection has been provided by the facility's qualified vendor. The improperly sealed hole noted in the kitchen hood was be properly sealed.
2. There is only one required semi-annual kitchen hood suppression system inspection, and the facility only has one kitchen hood, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Cooking Facilities specific to properly maintaining the facility's kitchen hood and suppression system. The semi-annual inspection will be added to the facility's TELS Preventative Maintenance (PM) Calendar, and will continue to be monitored in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to write and implement the required battery operated smoke detector policy in one instance, affecting the entire facility, per NFPA 72, Chapter 14.4.6;

Findings include:

1. Review of documentation and interview on May 26, 2022, at 8:45 a.m., revealed the facility failed to write and implement a battery operated smoke detector policy.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the facility failed to write and implement a battery operated smoke detector policy.







 Plan of Correction - To be completed: 07/19/2022

1. The facility will implement a battery operated smoke detector procedure.
2. There is only one requirement for a battery operated smoke detector procedure, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Fire Alarm System- Testing and Maintenance specific to properly a maintaining battery operated smoke detector procedure, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

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 01 - Component: 01 - Tag: 0353
Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instance, affecting the entire facility.

Findings include:

1. Review of documentation and interview on May 26, 2022, revealed the following required automatic sprinkler system testing documentation was missing:

a) 8:47 a.m. three quarterly sprinkler reports performed within the last 12 months;
b) 8:48 a.m., one annual sprinkler report performed within the last 12 months;
c) 8:49 a.m., an antifreeze solution test report performed within the last 12 months;
d) 8:50 a.m., a five year sprinkler report performed within the last five years.

Interview with the facility Administrator and the Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed that the above listed automatic sprinkler system documentation was not avaible at the time of the survey.









 Plan of Correction - To be completed: 07/19/2022

1. Documentation of three quarterly sprinkler reports, one annual sprinkler report, antifreeze solution test report, and five year sprinkler report will be provided by the facility's qualified vendor.
2. There is only one requirement for three quarterly sprinkler reports, an annual sprinkler report, an antifreeze solution test report, and a five year sprinkler report, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Sprinkler System- Maintenance and Testing specific to properly maintaining the required sprinkler system inspection reports. These items will be added to the facility's TELS Preventative Maintenance Calendar, and will continue to be monitored in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting four of four smoke compartments.

Findings include:

1. Observation on May 26, 2022, revealed the following smoke barrier door deficiencies:

a) 11:12 a.m., the A wing smoke barrier doors did not close in their frame when tested, and were unable to resist the passage of smoke;
b) 11:46 a.m., the C wing smoke barrier doors did not close and latch in their frame when tested, and were unable to resist the passage of smoke.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the above listed smoke barrier door deficiencies..




 Plan of Correction - To be completed: 07/19/2022

1. The A wing and C wing smoke barrier doors were repaired to properly close in their frames to block the passage of smoke.
2. Additional smoke barrier doors were reviewed for properly closing in their frames.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Subdivision of Building Spaces- Smoke Barrier Construction specific to maintaining smoke barrier doors to properly close in their frames, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Electrical Systems - Receptacles:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - 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: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of four smoke compartments.

Findings include:

1. Observation on May 26, 2022, at 11:58 a.m., revealed there was a broken electrical receptacle on the rear wall of the C wing lounge.

Interview with The Facility Administrator and the Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the electrical receptacle was damaged.




 Plan of Correction - To be completed: 07/19/2022

1. The broken receptacle noted on the rear wall of the C wing lounge was replaced.
2. Additional electrical receptacles will be reviewed for proper integrity.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Systems- Receptacles specific to properly maintaining the integrity of electrical receptacles, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined that the facility failed to maintain electrical receptacles in patient sleeping areas, affecting the entire facility.

Findings include:

1. Documentation review and interview on May 26, 2022, at 9:10 a.m., revealed the facility lacked documentation for an annual integrity, continuity, polarity and retention testing of electrical receptacles in the patient sleeping rooms. The most recent testing documentation of electrical receptacles, indicates receptacle testing was performed in May of 2020.

Interview with Facility Director and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the facility failed to perform the required annual test of electrical receptacles in patient sleeping areas, within the last two years.





 Plan of Correction - To be completed: 07/19/2022

1. The required annual electrical receptacle inspection will be completed by 6/30/22.
2. There is only one required annual electrical receptacle inspection, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Systems- Maintenance and Testing specific to completing the required electrical receptacle inspection annually. This item will be added to the facility's TELS Preventative Maintenance Calendar, and will continue to be monitored in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

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 documentation review and interview, it was determined the facility failed to maintain the emergency generator and automatic transfer switch, in four instances, affecting the entire facility.

Findings include:

1. Review of documentation and interview on May 26, 2022, at 8:58 a.m., revealed the facility failed to perform the following required emergency generator and automatic transfer switch, maintenance and testing:

a) Monthly conductance testing of the battery;
b) Monthly operation/function of the automatic transfer switch, testing shale be accordance with NFPA 110, 8.4.6.
c) Annual PM of the emergency generator, indicating no-evidence of wet stacking;
d) Annual fuel quality testing for the diesel powered emergency generator, maintenance shall be in accordance with NFPA 110, 8.3.8.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the facility failed to perform the above listed required testing and maintenance of the emergency generator and the automatic transfer switch.





 Plan of Correction - To be completed: 07/19/2022

1. Documentation of the required emergency generator monthly battery conductance testing and operation/function of the automatic transfer switch will be completed. Documentation of the required emergency generator annual Preventative Maintenance and fuel quality testing will be provided by a qualified vendor.
2. There is only one required monthly battery conductance testing and operation/function of the automatic transfer switch, and one required annual Preventative Maintenance and fuel quality testing, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Systems- Essential Electric System Maintenance and Testing specific to maintaining documentation of the required emergency generator monthly battery conductance testing and operation/function of the automatic transfer switch, and the annual emergency generator PM and fuel quality testing. These items will be added to the facility's TELS Preventative Maintenance Calendar, and will continue to be monitored in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Electrical Equipment - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in two instance, affecting one of four smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on May 26, 2022, revealed electrical panels blocked by storage in the following locations:

a) 11:21 a.m., in central supply;
b) 13:31 a.m., in the boiler room.

Interview with the Facility Administrator and Maintenance Director on May 26, 2022, at 1:30 p.m., confirmed the electrical equipment deficiencies.




 Plan of Correction - To be completed: 07/19/2022

1. The storage noted to be blocking the electrical panels in the central supply room and the boiler room was removed.
2. Additional electrical panels were reviewed for being improperly blocked by storage.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Other specific to maintaining electrical panels free of blockage by improper storage, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.


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