Pennsylvania Department of Health
KITTANNING HEALTH & REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 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.


KITTANNING HEALTH & REHAB 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 February 29, 2024, it was determined that Kittanning Health and Rehab Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

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.

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on February 29, 2024, at 11:30 a.m., revealed the facility lacked records to annually full-scale exercise, test, evaluate, and table-top exercise the emergency preparedness plan.

Interview with the maintenance supervisor on February 29, 2024, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 03/15/2024

To prevent this from recurring the Maintenance supervisor will do the following: 1) Conduct the necessary exercises as required by law for Emergency Preparedness. 2)Facility will record and maintain the necessary documentation for validation upon request. 3) Maintenance supervisor will present this documentation to the Nursing Home Administrator once a year in December, in order to ensure compliance.

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

Facility ID 234802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 29, 2024, it was determined that Kittanning Health and Rehab 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 483.9 (a).

This is a one-story, Type II (000), unprotected, non-combustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress Requirements - Other:

Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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.
18.2, 19.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200

Based on observation and interview, the facility failed to maintain evacuation diagrams throughout the building, affecting the entire facility.

Findings include:

Observation on February 29, 2024, between 9:25 a.m. and 11:04 a.m., revealed the evacuation diagrams did not contain a notation showing the location of the viewer, which could delay exterior egress.

Ref: NFPA 170-11.2.4 and 11.3.2

Interview with the maintenance director on February 29, 2024, at 11:04 a.m., confirmed the deficiency for egress evacuation.

Plan of Correction - To be completed: 03/15/2024

Facility has corrected all evacuation diagrams to show exactly where the person is for proper evacuation.

NFPA 101 STANDARD Exit Signage:

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.

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

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

Based on observation and interview, the facility failed to maintain emergency exit signs for four of over twenty signs.

Observation on February 29, 2024, between 10:01 a.m. and 10:53 a.m., revealed the following exit sign deficiencies:
A. (10:01 a.m.) Main floor door to courtyard, leading from the cafeteria, failed to display a "No Exit" sign;
B. (10:50 a.m.) Main floor east entrance to the cafeteria failed to display an illuminated exit sign that would maintain egress continuity when the doors are closed;
C. (10:52 a.m.) Main floor double doors to the right of the east entrance to the cafeteria failed to display an illuminated exit sign;
D. (10:53 a.m.) Main floor east entrance to the cafeteria had a non-illuminated (paper) exit sign with an incorrect directional arrow to the egress path to the main entrance.

Interview with the maintenance director on February 29, 2024, at 10:53 a.m., confirmed the exit sign deficiencies.

Plan of Correction - To be completed: 03/15/2024

To keep this from reoccurring, the Maintenace supervisor has purchased and installed the necessary directional signs that feature continuous illumination. Maintenance supervisor has also been instructed to remove the no exit sign, which was above the door that exits into the enclosed courtyard. Since this facility has removed the incorrect sign from the door, this action has ensured that the problem will not recur.

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 maintain the kitchen suppression system, affecting one of one kitchen.

Findings include:

Document review on February 29, 2024, at 9:37 a.m., revealed the kitchen fire suppression inspection report, dated February 2, 2024, listed deficiencies not corrected at the time of the survey:
A) No detection under ducts;
B) Additional nozzles needed;
C) Convention oven and steamer do not shut down when tripped;
D) Duct seams need welded;
E) Pull station need lowered.

Interview with the maintenance supervisor on February 29, 2024, at 9:37 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 03/15/2024

To correct and keep this problem from reoccurring,
this Facility had the fire suppression system re-inspected and is now in compliance. Maintenance supervisor has been informed to have this inspection every year in December and present proof to the administrator of compliance.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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

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

Based on document review and interview, the facility failed to maintain fire alarm system testing, affecting the entire building.

Findings include:

Document review on February 29, 2024, revealed the facility lacked two-year smoke detector sensitivity testing documentation at the time of the survey.

Interview with the maintenance supervisor on February 29, 2024, confirmed the missing documentation.

Plan of Correction - To be completed: 03/15/2024

To correct this problem, the maintenance supervisor has had the facility smoke detector sensitivity test completed. To ensure that it does not recur, the maintenance supervisor will conduct the test yearly and present proof to the administrator id December of each year.

NFPA 101 STANDARD Smoke Detection:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on observation and interview, the facility failed to provide smoke detectors and alarms in eleven of over fifty rooms.
Findings include:

Observation on February 29, 2024, at 9:04 a.m., revealed the main floor administration offices failed to have smoke detection devices installed in eleven rooms, potentially causing a delay in facility alarm activation during unoccupied time periods.

Ref: NFPA 101 - 9.6.1.8

Interview with the maintenance supervisor on February 29, 2024, at 9:04 a.m., confirmed the lack of smoke detectors in the administration offices.

Plan of Correction - To be completed: 03/15/2024

To correct this problem and ensure that it does not recur, the maintenance has purchased and installed the eleven smoke detectors that were identified as missing. Each year he will conduct an audit ensuring that the detectors are still in place and working properly. He will submit proof of such inspection in December of each year.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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

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

Based on observation and interview, the facility failed to maintain the sprinkler system for over twenty sprinkler heads affecting the entire facility.

Findings include:

Observation on February 29, 2024, between 9:24 a.m., and 10:52 a.m., revealed loose, missing, or broken sprinkler head escutcheons, that created an opening in the ceiling, possibly delaying sprinkler activation.

Interview with the maintenance director on February 29, 2024, at 10:52 a.m., confirmed the sprinkler escutcheon plates lacked maintenance and repair.

Plan of Correction - To be completed: 03/15/2024

To keep this issue from recurring the maintenance supervisor will conduct a visual audit each year in December
so that the facility maintains compliance. Facility has made the necessary changes so that the delayed activation possibility is no longer a factor.

NFPA 101 STANDARD Portable Fire Extinguishers:

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

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

Based on observation and interview, the facility failed to maintain portable fire extinguishers in two of over twenty rooms.

Findings include:

Observation on February 29, 2024, between 9:09 a.m. and 9:12 a.m., revealed the main floor administration department had the following fire extinguisher deficiencies:
A. (9:09 a.m.) Administration department conference room had blocked access and visibility to the fire extinguisher, which was also not properly mounted.
B. (9:12 a.m.) Administration department at receptionist desk had blocked access and visibility to the fire extinguisher, which was also not properly mounted.

Interview with the maintenance director on February 29, 2024, at 9:12 a.m., confirmed the above fire extinguisher deficiencies.

Plan of Correction - To be completed: 03/15/2024

In order to keep this issue from recurring the maintenance super will conduct an audit in December of each year and submit proof the NHA that all of the fire extinguishers are hung at the proper height.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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, it was determined that the facility failed to maintain smoke barrier construction in thirty of over sixty rooms, affecting the entire building.

Findings include:

Observations on February 29, 2024, between 9:24 a.m., and 10:52 a.m., revealed the ceiling tiles lacked maintenance throughout the main floor and basement levels, with loose, misaligned, broken, and missing tile and grid system present, possibly allowing smoke to spread throughout the facility.

Interview with the maintenance supervisor on February 29, 2024, at 10:52 a.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 03/15/2024

In order to keep this problem from recurring the maintenance super will conduct a visual audit in December of each year to ensure that all ceiling tiles are properly fitting so that smoke does not have access to residents rooms. All rooms have been inspected and the necessary corrections were made in order to ensure compliance with the smoke compartment requirements involving ceiling tile.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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, the facility failed to maintain electrical receptacles in two of over fifty rooms.

Findings include:

Observation on February 29, 2024, between 9:51 a.m. and 10:54 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations:
A. (9:51 a.m.) Main floor, ice machine room, unable to verify GFCI or dedicated circuit;
B. (10:44 a.m.) Main floor, rehab therapy room.

Interview with the maintenance director on February 29, 2024, at 10:54 a.m., confirmed the above electrical outlet deficiencies.

Plan of Correction - To be completed: 03/15/2024

In order to ensure that this problem does not recur, the maintenance will reaudit the facility in December of each year so that the facility has the necessary GFCI outlets at each location. The facility corrected this problem by purchasing and installing the proper outlets in the areas that were out of compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 - 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 maintain essential electric system maintenance and testing for one of one emergency generator.

Findings include:

Document review on February 29, 2024, at 9:55 a.m., revealed the facility lacked documentation for the following emergency generator testing requirements:
A) Failed to provide an acceptable annual fuel analysis report. Fuel sample report, dated February 7, 2024, noted elevated particulates;
B) Failed to provide monthly battery, specific gravity, or conductance testings.

Interview with the maintenance supervisor on February 29, 2024, at 9:55 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 03/15/2024

In order to ensure that this problem does not recur, the maintenance super will now have the Diesel fuel tested twice per year. This additional audit, halfway through the year, will ensure that the diesel fuel is clean and does not have particles that could deter the system from working properly. Facility has had the generator fuel tested and made the necessary adjustments to comply with the elevated particles requirement. Upon completion the maintenance super will provide verification that shows that the diesel is being kept clean. Monthly battery testing has now been completed, Maintenance super will maintain a log indicating proof of such inspection.

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