Pennsylvania Department of Health
BRYN MAWR EXTENDED CARE CENTER
Building Inspection Results

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BRYN MAWR EXTENDED CARE CENTER
Inspection Results For:

There are  50 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.
BRYN MAWR EXTENDED CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on February 12, 2024, it was determined that Bryn Mawr Extended Care Center was not in compliance with the requirements of 42 CFR 483.73.







 Plan of Correction:


403.748(b)(2), 416.54(b)(1), 418.113(b)(6)(ii) and (v), 441.184(b)(2), 482.15(b)(2), 483.475(b)(2), 483.73(b)(2), 485.542(b)(2), 485.625(b)(2), 485.920(b)(1), 486.360(b)(1), 494.62(b)(1) STANDARD Procedures for Tracking of 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)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1).

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

[(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0018


Based on documentation review and interview, it was determined the facility failed to develop Emergency Plan policies and procedures that included a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency this is effecting the entire facility.

Findings include:

Document review on February 12, 2024, at 8:15 a.m., revealed the Facility's Emergency Preparedness Plan did not include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location if on-duty staff and sheltered patients are relocated during an emergency.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the documentation was not available.









 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete with specific name and location of receiving facility.
2. EPP will be updated as needed.
3. Education completed to Director of
Maintenace to location of EPP and
ensure EPP updated.
4. NHA / MD will review and update EPP
quarterly
5. Audit results will be reviewed at QAPI
for recommendations and revisions.


403.748(b)(4), 416.54(b)(3), 418.113(b)(6)(i), 441.184(b)(4), 482.15(b)(4), 483.475(b)(4), 483.73(b)(4), 485.542(b)(4), 485.625(b)(4), 485.68(b)(2), 485.727(b)(2), 485.920(b)(3), 491.12(b)(2), 494.62(b)(3) STANDARD Policies/Procedures for Sheltering in Place: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)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3).

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

[(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility].

*[For Inpatient Hospices at §418.113(b):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.
Observations:
Name: - Component: -- - Tag: 0022

Based on document review and interview, it was determined the facility failed to include a Policy and Procedure for Sheltering in place effecting the entire facility.

Findings include:

Observation made on February 12, 2024, between 8:30 a.m. and 10:00 a.m., revealed the Emergency Preparedness Manual did not include documentation of a means to shelter in place for patients, staff, and volunteers who remain in the facility.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024, at 12:30 p.m., confirmed the missing documentation.








 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete documentation for sheltering in place
2. EPP updated as needed
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(b)(5), 416.54(b)(4), 418.113(b)(3), 441.184(b)(5), 482.15(b)(5), 483.475(b)(5), 483.73(b)(5), 484.102(b)(4), 485.542(b)(5), 485.625(b)(5), 485.68(b)(3), 485.727(b)(3), 485.920(b)(4), 486.360(b)(2), 491.12(b)(3), 494.62(b)(4) STANDARD Policies/Procedures for Medical Documentation: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)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).


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

[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Name: - Component: -- - Tag: 0023

Based on documentation review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures that included a system of medical documentation for patients, affecting the entire facility.

Findings Include:

Documentation review on February 12, 2024, at 8:30 a.m., revealed facility failed to develop Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024, at 12:30 p.m., confirmed the documentation was not available.








 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete documentation for preserving patient information, securing and maintaining availability of records
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(b)(6), 416.54(b)(5), 418.113(b)(4), 441.184(b)(6), 482.15(b)(6), 483.475(b)(6), 483.73(b)(6), 484.102(b)(5), 485.542(b)(6), 485.625(b)(6), 485.68(b)(4), 485.727(b)(4), 485.920(b)(5), 491.12(b)(4), 494.62(b)(5) STANDARD Policies/Procedures-Volunteers and Staffing: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)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).

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

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Name: - Component: -- - Tag: 0024

Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing the use of volunteers in an emergency. affecting the entire facility.

Findings include:

Document review on February 12, 2024, between 8:30 a.m. and 9:00 a.m., revealed the Facilities Emergency Preparedness Plan did not have policy and procedures addressing the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, affecting the entire facility.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024 at 12:30 p.m., confirmed the Emergency Preparedness plan did not include policy and procedures for use of volunteers during an emergency.









 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete for documentation for use of volunteers during an emergency
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

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

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

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to provide policy and procedure documentation concerning the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials, affecting the entire facility.

Findings include:

Document review on February 12, 2024, between 8:30 a.m. 9:30 a.m., revealed the facility could not provide Emergency Preparedness Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary.

Interview at the exit conference with the Facility Administrator and the Maintenance Supervisor on February 12, 2024 at 12:30 p.m., confirmed the Emergency.







 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete documentation for the roles under a waiver declared by Secretary
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 482.15(c)(1), 483.475(c)(1), 483.73(c)(1), 484.102(c)(1), 485.542(c)(1), 485.625(c)(1), 485.68(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1) STANDARD Names and Contact Information: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(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).

[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan that included a communication plan containing all the required contact information, affecting the entire facility.

Findings include:

Review of documentation on February 12, 2024 at 8:45 a.m., revealed the facility did not have an an Emergency Preparedness Communication plan that included names and contact information for transfer facilities that would receive residents in the event of an evacuation.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the documentation was not available.








 Plan of Correction - To be completed: 03/18/2024

2. EPP reviewed and complete documentation for communication plan containing required contact information.
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication: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(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Name: - Component: -- - Tag: 0032

Based on document review and interview, it was determined the facility failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means of communicating, affecting the entire facility.

Findings include:

Document review on February 12, 2024 at 8:45 a.m., revealed the facility's emergency preparedness communication plan did not include a primary and alternate means of communicating with the following:

(i) Facility's staff.
(ii) Federal, State, tribal, regional, and local emergency management
agencies.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024, at 12:30 p.m., confirmed the documentation was not available.







 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete documentation for primary and alternate means of communication
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(c)(4)-(6), 416.54(c)(4)-(6), 418.113(c)(4)-(6), 441.184(c)(4)-(6), 482.15(c)(4)-(6), 483.475(c)(4)-(6), 483.73(c)(4)-(6), 484.102(c)(4)-(5), 485.542(c)(4)-(6), 485.625(c)(4)-(6), 485.68(c)(4), 485.727(c)(4), 485.920(c)(4)-(6), 491.12(c)(4), 494.62(c)(4)-(6) STANDARD Methods for Sharing Information: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(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.

(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)]

(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).

*[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.

*[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Name: - Component: -- - Tag: 0033

Based on document review and interview, it was determined the facility's emergency preparedness communication plan failed to include a method for sharing information and medical documentation for patients, affecting the entire facility.

Findings include:

Document review on February 12, 2024, at 8:45 a.m., revealed the facility's emergency preparedness communication plan lacked a method for sharing information and medical documentation for patients under the facility's care, with other health care providers to maintain the continuity of care.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024, at 12:30 p.m., confirmed the documentation was not available.







 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete documentation for communication to include sharing information and medical documentation for patients, affecting entire facility.
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(c)(7), 416.54(c)(7), 418.113(c)(7), 441.184(c)(7), 482.15(c)(7), 483.475(c)(7), 483.73(c)(7), 484.102(c)(6), 485.542(c)(7), 485.625(c)(7), 485.68(c)(5), 485.727(c)(5), 485.920(c)(7), 491.12(c)(5), 494.62(c)(7) STANDARD Information on Occupancy/Needs: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(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, it was determined the facility's emergency preparedness communication plan did not include a means of providing information about the Facility's needs affecting the entire facility.

Findings include:

Document review on February 12, 2024 at 8:45 a.m., revealed the facility's emergency preparedness communication plan did not include a means of providing information about the Facility's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024 at 12:30 p.m., confirmed the documentation was not available.







 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete documentation for providing information about the facility needs and its ability to provide assistance to the authority having jurisdiction.
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with 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.
§483.73(c)(8); §483.475(c)(8)

*[For LTC Facilities at §483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at §483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, it was determined the facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan, with residents and their families or representatives.

Findings include:

Document review and interview on February 12, 2024 at 8:45 a.m., revealed the emergency communications plan did not include a method of sharing information from the emergency plan with residents and their families or representatives, affecting the entire facility.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor on February 12, 2024 at 12:30 p.m., confirmed the emergency communications plan did not include a method of sharing information from the emergency plan with residents and their families or representatives.









 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training 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.
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Name: - Component: -- - Tag: 0036

Based on documentation review and interview, it was determined the facility failed to develop
an emergency preparedness training program that is based on the facility's emergency preparedness plan affecting the entire facility.

Findings include:

Document review on February 12, 2024 at 8:45 a.m., revealed the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan and completed annually.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the documentation was not available.









 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and complete
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

403.748(d)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program: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(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Name: - Component: -- - Tag: 0037

Based on documentation review and interview, it was determined the facility failed to maintain a training program that is based on the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

Review of documentation on February 12, 2024 at 8:45 a.m., revealed the facility failed to perform training to the emergency preparedness plan that included the following:

a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
b. Provide emergency preparedness training at least annually.
c. Maintain documentation of the training.
d. Demonstrate staff knowledge of emergency procedures.

Interview at the exit conference with the Facility Administrator and Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the documentation was unavailable.









 Plan of Correction - To be completed: 03/18/2024

1. EPP reviewed and emergency training prepardness training provided
2. EPP updated as needed / required
3. Education competed to Maintenance
Director to location of EPP and ensure
EPP updated as needed
4. NHA/MD will review and update EPP
quarterly
5. Audit results will be reviewed
quarterly by QAPI for recommendations
and revision

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


Facility ID# 032002
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on February 12, 2024, it was determined that Bryn Mawr Extended Care Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

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





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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

Based on document review and interview, it was determined the facility failed to provide accurate, portable floor plans as required; affecting the entire facility.

Findings Include:

Document review on February 12, 2024, at 8:15 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

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

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed accurate floor plans were not available.

2. Document review on February 12, 2024, at 8:15 a.m., revealed the facility failed to provide a carbon monoxide alarm evacuation plan.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the facility did not adhere to the Care Facility Carbon Monoxide Alarms Standards Act.






 Plan of Correction - To be completed: 03/18/2024

1. Set of accurate portable floors plans
are available
2. Carbon Monoxide alarm evacuation plan
present and in the EPP
3. Education provided to Maintenance
Director to ensure portable floor plans
are available at all times
4. Audits to be completed monthly to
ensure portable floor plans are
available
5. Audit results will be reviewed monthly
by QAPI

NFPA 101 STANDARD Egress Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain delayed-egress doors, affecting one of three levels in the facility.

Findings include:

Observation on February 12, 2024, at 12:05 p.m., revealed the delayed-egress door by First floor Kitchen lacked signage stating:

"PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS"

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of signage.








 Plan of Correction - To be completed: 03/18/2024

1. Signage to first floor kitchen door
placed
2. Education provided to Maintenance
Director to ensure all egress doors
with correct signage
3. Audit to be completed monthly to ensure
correct signage on egress doors.
4. Audit results will be reviewed monthly
by QAPI for recommendations

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, affecting one of three levels in the facility.

Observation on February 12, 2024 at 12:15 p.m. determined the following:

1. Unsecured hardware on self closing fire door not latching
2. Self closing Fire door binding to the kitchen door frame

Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the deficiencies.









 Plan of Correction - To be completed: 03/18/2024

1. Hardware to self closing fire door is
latching
2. Self closing door to the kitchen door
frame is not binding
3. Education proved to Maintenance
Director and Housekeeping Director to
ensure all self closing fire doors
hardware are secure and latching and
self closing fire doors are not
binding.
4. Audit to be completed monthly for 60
days to ensure all self closing fire
door hardware is secure and no self
closing fire doors are binding
5. Audit results will be reviewed
by QAPI for recommendations

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




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

Based on observation and interview, it was determined the facility failed to maintain the smokeproof enclosure of the stairwell, affecting one of three levels in the facility.

Findings include:

Observation on February 12, 2024, at 11:50 a.m., revealed, in the First floor A wing Stairwell, storage under the stairs.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the improper storage under the stairs.




 Plan of Correction - To be completed: 03/18/2024

1. Items removed from first floor A wing
stairwell.
2. Education provided to Maintenance
Director and Housekeeping Director,
nothing to be stored under stairwell
4. Random audit to be completed weekly for
4 weeks to ensue no storage under
stairwells.
5. Audit results will be reviewed
by QAPI for recommendations

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, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting the entire facility.

Findings include:

Document review on February 12, 2024, at 8:15 a.m., revealed the facility could not provide documentation of the following maintenance items and tests:

a. Semi-annual kitchen hood cleaning within 6 months prior to 11/29/2023;
b. Monthly inspections of the kitchen hood suppression system.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 03/18/2024


1. Semi annual hood cleaning completed
November of 2023 and next scheduled
hood cleaning is scheduled for May of
2024
2. Monthly inspection of kitchen hood
suppression completed
3. Education provided to Maintenance
Director to ensure monthly inspection
of kitchen hood suppression are
completed
4. Monthly audits x 3 months to ensure
inspection of kitchen hood
suppression completed.
5. Audit results will be reviewed by
QAPI for recommendations


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility.

Findings include:

Document review on February 12, 2024, at 8:15 a.m., revealed the facility could not provide documentation of a semi-annual fire alarm inspection within 6 months after 1/12/2023.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 03/18/2024

1. Fire Alarm inspection completed February 2024.
2. Education provided to Maintenance Director ensuring that semi annual fire inspections are conducted and scheduled.
3. Audit by NHA / designee to ensure semi annual fire alarm inspections are scheduled
4. Audits to QAPI for review
NFPA 101 STANDARD Sprinkler System - 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.
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 document review, observation, and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

1. Document review on February 12, 2024, at 8:15 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. Semi-annual valve supervisory switches and waterflow alarm devices tests within 6 months of 1/15/24;
b. Quarterly sprinkler inspection for the 3rd quarter of 2023;
c. Annual partial trip test of the dry sprinkler system;
d. 3 year full trip test of the dry sprinkler system.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of documentation.

2. Observation on February 12, 2024, revealed the ceiling was missing at the following areas:
a. First floor electric room, 12:10 p.m.
a. Basement Linen Folding storage room, 12:13 p.m.
b, Basement Laundry room, 12:14 p.m.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of ceiling.






 Plan of Correction - To be completed: 03/18/2024

1. Semi annual valve supervisor switches
and waterflow alarm devices test
scheduled for July of 2024.
2. Quarterly sprinkler inspection
completed on 1/15/2024 and due April
of 2024
3. Annual partial trip test of the dry
sprinkler system was completed May of
2023 and due May of 2024
4. 3 year full trip test of dry
sprinkler system was completed May of
2023 and due May of 2026
5. Education provided to Maintenance
Director ensuring semi annual valve
supervisor switched and waterflow
alarm devive are on a semi annual
schedule, ensuring quarterly
sprinkler inspection are quaterly,
partial trip test are annual and the
3 year trip test every 3 years.
6. Audit review to QAPI for
recommendations.
NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings include:

1. Observations on February 12, 2024, between 11:23 a.m. and 12:15 p.m., revealed the portable fire extinguishers were missing monthly inspections in the following locations:

a. 11:23 a.m., on the second floor, across from resident room 242;
b. 11:37 a.m., on the second floor, next to resident room 217;
c. 11:42 a.m., on the second floor, next to resident room 205;
d. 11:46 a.m., on the second floor, Activities;
e. 12:02 p.m., on the first floor, across from Gym;
f. 12:14 p.m., basement, Central Supply;
g. 12:15 p.m., basement both extinguishers in Boiler Room.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of inspections.

2. Observations on February 12, 2024, between 11:23 a.m. and 11:58 a.m., revealed the indicator light above the portable fire extinguishers was burnt out in the following locations:

a. 11:23 a.m., on the second floor, across from resident room 242;
b. 11:42 a.m., on the second floor, next to resident room 205;
c. 11:52 a.m., on the first floor, across from resident room 114;
d. 11:58 a.m., on the first floor, Nurses Station.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the indicator lights were burned out.




 Plan of Correction - To be completed: 03/18/2024

1. Inspection of the portable fire
extinguishers completed.
2. Indicator lights on the second floor
across from room 242,on second floor
next to resident room 217, on second
floor next to resident room 205, on
second floor activities, on first f
floor
across from gym, basement central
supply and basement bot
extinguishers.
in boiler room have been replaced.
3. Education provided to Maintenance
Director to ensure indicator lights
are working.
4. Monthly audits for 3 months to ensure
indicator lights are working.
5. Results to QAPI for review
NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation, the facility failed to comply with NFPA 70, National Electric Code, for the electrical wiring and equipment, affecting one of three levels in the facility.

Findings include:

Observation on February 12, 2024, at 12:11 p.m., revealed an open junction box above the ceiling near in the basement Linen Folding storage room.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the open junction box.





 Plan of Correction - To be completed: 03/18/2024

1. Open junction box above the ceiling
near the basement linen folding storage
room sealed.
2. Education provided to Maintenance
Director on ensuring open junction
boxes are sealed after any electrical
work in the celing.
3. Maintenance Director will audit monthly
x 3 months for any electrical work
completed in the ceiling are sealed.
4. Audit results to QAPI.
NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of laundry chutes, affecting two of three levels in the facility.

Findings include:

1. Observations on February 12, 2024, between 11:27 a.m. and 12:04 p.m., revealed the following deficiencies:
a. 11:27 a.m., on the second floor, Soiled Linen chute by Freight Elevator, chute door would not latch;
b. 11:54 a.m., on the first floor, Soiled Linen room, door lacked fire rated hardware;
c. 12:04 p.m., on the first floor, Soiled Linen chute by Freight Elevator, chute door would not latch.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the above deficiencies.





 Plan of Correction - To be completed: 03/18/2024

1. Second floor soiled linen chute by
freight elevator latches, first floor
soiled line room with fire rated
hardware, first floor soiled linen
chute by freight elevator door latches.
2. Education provided to Maintenance
Director and Housekeeping Director to
ensure all soiled linen chutes latch
and have fire rated hardware.
3. Monthly audits x 3 months by
Maintenance Director to ensure soiled
linen chutes latch and fire rated
hardware present.
4. Results to QAPI for review
NFPA 101 STANDARD Electrical Systems - Receptacles: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 - 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 documentation review and interview, it was determined the facility failed to ensure that electrical receptacles were tested in patient care rooms and at deep sedation bed locations, within the facility.

Findings include:

Document review on February 12, 2024, at 8:15 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the facility could not provide documentation that the receptacles were tested.





 Plan of Correction - To be completed: 03/18/2024

1. Receptacles tested in resident rooms
2. Education provided to Maintenace
Director to ensure receptacle testing
in patient rooms are preformed yearly
not exceeding 12 months.
3. Audit by NHA/Maintenance Director to
ensure yearly inspection of receptacles
not exceeding 12 months conducted.
4. Audit results to QAPI
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 Receptacles
Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0917

Based on documentation review and interview, it was determined the facility failed to maintain and ensure protection of the following electrical equipment in two of thre levels

Observations on February 12, 2024, between 11:30 a.m. and 12:10 p.m., revealed the following deficiencies:

1. Receptacle missing GFCI protection at the hallway sink on the second floor, outside of the soiled linen room
2. Unsecured electrical panel cover inside the electrical room on the second floor.
3. Unprotected/Abandoned wiring in the hallway ceiling, outside room 128

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the deficiencies listed above.








 Plan of Correction - To be completed: 03/18/2024

1. GFCI protection to the hallway sink
on the second floor outside of the
soiled linen room placed. Electrical
panel cover secured on the second
floor. Wiring in the hallway ceiling
outside of room 128 capped.
2. Education provided to Maintenance
Director to ensure protection of
electrical equipment.
3. Audits monthly x 3 months by
Maintenance director to ensure
electrical equipment secured and
protected.
4. Audit results to QAPI for 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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on February 12, 2024, at 8:15 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. Monthly testing of battery electrolyte specific gravity or conductance testing;
b. Annual 90 minute load bank test;
c. Preventative maintenance report indicating there was no evidence of wet-stacking.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 03/18/2024

1. Monthly testing of battery electrolyte specific gravity or conductance testing completed for the month. Annual test load bank test completed March of 2023. Preventative Maintenance report completed indicating no evidence of wet stacking.
2. Education provided to Maintenance Director ensuring that monthly battery testing completed, annual 90 minute load completed and preventative maintenance reports are conducted.
4. Monthly audits x 3 months to ensure monthly battery testing and preventative maintenance reports are completed by NHA/ designee
5. Audits to QAPI for review
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to secure oxygen tanks, affecting two of the three floors.

Unsecured oxygen tanks observed in the following areas:
1. On the first floor, medication room, February 12, 2024, 11:50 a.m.
2. On the second floor, medication room, February 12, 2024, 11:23 a.m.

Exit Interview with the Facility Administrator and the Maintenance Supervisor, on February 12, 2024 at 12:30 p m , confirmed unsecured oxygen tanks.










 Plan of Correction - To be completed: 03/18/2024

1. Oxygen tanks secured on the first floor and second floor medication rooms.
2. Education provided to Maintenance Director to ensure all oxygen tanks are secured.
3. Audits monthly x 3 months by Maintenance Director too ensure all oxygen tanks are secured.
4. Audits to QAPI for review.

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