Pennsylvania Department of Health
CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CEDARWOOD REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  43 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.
CEDARWOOD REHABILITATION & HEALTHCARE 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 7, 2024, it was determined that Cedarwood Rehabilitation and Healthcare 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(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 a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to include names and contact information.

Findings include:

1. Interview and documentation review of the facility EP plan on February 7, 2024, at 12:30 p.m., revealed the EP Plan did not include updated and accurate names and contact information for (i) Staff and (ii) Residents physicians.

Interview with the Facility Administrator and Maintenance Director on February 7, 2024, at 1:30 p.m., confirmed the listed EP plan deficiency.






 Plan of Correction - To be completed: 02/29/2024


Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the
statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.

1. The facility's Emergency Preparedness manual was updated to include the current staff roster and the name of the Medical Director.
2. The Emergency Preparedness manual will have the staff and physician roster updated quarterly at the monthly safety committee meeting.
3. The facility's Safety Director will notify the facility's Quality Assurance and Performance Improvement committee of quarterly updates to the Emergency Preparedness manual.
4. Date of compliance is 2/29/24.

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 a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to meet the Emergency Prep Testing Requirements of the emergency plan, for one of two exercises, affecting the entire facility.

Findings include:

1. Interview and documentation review of the facility EP plan on February 7, 2024, at 12:30 p.m., revealed the facility failed to meet the annual requirements of section (B) tabletop exercise.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed EP plan deficiency.



 Plan of Correction - To be completed: 02/29/2024

1. The facility will conduct another tabletop disaster drill.
2. The Administrator will retrain the Safety Director on the requirements for emergency preparedness drills in accordance with requirements of E0039.
3. The facility's Safety Director will notify the facility's Quality Assurance and Performance Improvement committee upon completion of the required disaster drills.
4. Date of compliance is 2/29/24.

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power: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.
§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..
Observations:
Name: - Component: -- - Tag: 0041

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly testing in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on February 7, 2024, at 11:30 a.m., revealed the facility failed to perform the required monthly conductance testing of the emergency generator battery in the past twelve months.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed emergency generator battery testing deficiency.



 Plan of Correction - To be completed: 02/29/2024

1. The facility has purchased the necessary equipment to complete the monthly conductance testing of the battery on the emergency generator.
2. The Administrator will retrain the Maintenance Director on the requirement for monthly testing for the generator battery as required in E0041.
3. The facility's Safety Director will monitor compliance of the monthly battery tests at the Safety Meeting and review the findings with the facility's Quality Assurance and Performance Improvement committee.
4. Date of compliance is 2/29/24.

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

Facility ID# 050802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 7, 2024, it was determined that Cedarwood Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire-resistive structure, with a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311


Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosure in one instance, affecting two of nine smoke compartments.

Findings include:

1. Observation on February 7, 2024, at 9:18 a.m., revealed there was unsealed ductwork penetrating the concrete deck in central supply above the chiller unit.


Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed vertical opening enclosure deficiency.




 Plan of Correction - To be completed: 02/29/2024

1. The penetration in the concrete deck in the central supply room has been properly sealed.
2. The Maintenance Director will conduct an inspection of the concrete decks in the facility to ensure there are no more unsealed penetrations.
3. The Maintenance Director will present findings at the monthly Safety Committee meeting regarding and findings and corrections of unsealed penetrations. These findings will be reviewed at the Quality Assurance and Performance Improvement committee meetings.
4. Date of compliance is 2/29/24.


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 documentation review and interview, it was determined the facility failed to perform fire alarm system testing and maintenance in two instances, affecting the entire facility.

Findings Include:

1. Review of documentation on February 7, 2024, revealed fire alarm testing documentation was not readily available, at the time of the survey, for the following:

a) 11:30 a.m., a semi-annual visual inspection performed within the past twelve months;
b) 11:32 a.m., biennial smoke detector sensitivity testing (last performed on November 13, 2024).

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the missing fire alarm system testing documentation.




 Plan of Correction - To be completed: 02/29/2024

1. A biennial smoke detector survey was completed on 5/9/2022 and documentation of this inspection was furnished to the surveyor on 2/13/24. The facility will have a semi-annual visual inspection completed.
2. The Administrator will retrain the Maintenance Director on the biennial smoke detector survey and semi-annual visual inspection as required by K0345.
3. The Maintenance Director will present findings at the monthly Safety Committee meeting regarding and findings and completion of required alarm system inspections. These findings will be reviewed at the Quality Assurance and Performance Improvement committee meetings.
4. Date of compliance is 2/29/24.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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, it was determined the facility failed to maintain the automatic sprinkler system in nine instances, affecting seven of nine smoke compartments.

Findings include:

1. Observation on February 7, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:22 a.m., there was a sprinkler branch line in the basement biohazard room that has scaled rust on the outside of the pipe where water from an above-water pipe has been leaking on it for a long period;
b) 9:33 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the storage closet located in the activities office;
c) 9:37 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were multiple unsealed penetrations in the first-floor communication room by the break room;
d) 9:50 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. The support track for the drop ceiling is hanging down in the rear of the Admissions office;
e) 9:52 the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. The sprinkler head escutcheon in the business office was unable to touch the ceiling and create a smoke resistive seal;
f) 9:53 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were missing ceiling tiles in the chapel;
g) 10:13 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. The sprinkler head escutcheon in the fourth-floor dining room was unable to touch the ceiling and create a smoke resistive seal;
h) 10:35 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were missing ceiling tiles in the third-floor med room;
i) 11:00 a.m., the protective caps/covers on the fire department connection were missing.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m. confirmed the listed automatic sprinkler system deficiencies.


 Plan of Correction - To be completed: 02/29/2024

1. The facility has contracted to have the sprinkler line with scaled rust replaced in the basement. The items in the activity closet stored above 18" have been removed. The unsealed ceiling penetrations in the communications room have been repaired. The ceiling support track in the Admissions office has been repaired. The sprinkler head escutcheon in the business office has been repaired. The missing ceiling tiles in the chapel have been replaced. The sprinkler head escutcheon in the 4th floor dining room has been repaired. The missing ceiling tiles in the 3rd floor med room have been replaced. The missing caps on the fire department connection have been replaced.
2. The Administrator will retrain the Maintenance Director on the biennial smoke detector survey and semi-annual visual inspection as required by K0345.
3. The Maintenance Director will present findings at the monthly Safety Committee meeting regarding and findings and corrections of rusted sprinkler pipe, unsealed ceilings penetrations, missing tile and storage distance from the ceiling. These findings will be reviewed at the Quality Assurance and Performance Improvement committee meetings.
4. Date of compliance is 2/29/24.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills affecting the entire facility.

Findings include:

1. Review of documentation on February 7, 2024, at 11:30 a.m., revealed the facility lacked documentation for a fourth-quarter fire drill for the third shift.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed fire drill deficiency.



 Plan of Correction - To be completed: 02/29/2024

1. The facility is unable to go back and provide correction on this issue.
2. The Administrator will retrain the Maintenance Director and Staff Development Coordinator on the requirement in K0712 for fire drills to be completed quarterly on all three shifts.
3. The Maintenance Director will present findings at the monthly Safety Committee meeting regarding the completion of the fire drills. These findings will be reviewed at the Quality Assurance and Performance Improvement committee meetings.
4. Date of compliance is 2/29/24.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in two instances, affecting two of nine smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code NFPA 101, 19.5.1.1,


Findings include:

1. Observation on February 7, 2024, revealed unterminated electrical wiring in the following locations:

a) 10:01 a.m., there was an open electrical junction box above the ceiling at the smoke barrier doors by the administration offices (elevator side of the doors) leaving exposed wiring;
b) 10:35 a.m., there were unterminated electrical wires hanging from the ceiling light fixture in the third-floor med room.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed electrical wiring deficiencies.




 Plan of Correction - To be completed: 02/29/2024

1. The junction box cover in the ceiling by the elevator was secured. The light fixture with the exposed wire in the 3rd floor med room has been repaired.
2. The Maintenance Director and/or designee will conduct a visual inspection of all junction boxes to ensure they are covered and all light fixtures to ensure there are no exposed wires.
3. The Maintenance Director and/or designee will do a visual inspection monthly for three months of all light fixtures and junction boxes and report his finding at the monthly Safety Committee meeting. These findings will be reviewed at the Quality Assurance and Performance Improvement committee meetings.
4. Date of compliance is 2/29/24.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly testing in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on February 7, 2024, at 11:30 a.m., revealed the facility failed to perform the required monthly conductance testing of the emergency generator battery in the past twelve months.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed emergency generator battery testing deficiency.




 Plan of Correction - To be completed: 02/29/2024

1. The facility has purchased the necessary equipment to complete the monthly conductance testing of the battery on the emergency generator.
2. The Administrator will retrain the Maintenance Director on the requirement for monthly testing for the generator battery as required in K0918.
3. The facility's Safety Director will monitor compliance of the monthly battery tests at the Safety Meeting and review the findings with the facility's Quality Assurance and Performance Improvement committee.
4. Date of compliance is 2/29/24.

NFPA 101 STANDARD Electrical Equipment - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

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

Findings include:

1. Observation on February 7, 2024, revealed the following electrical panels were blocked by storage:

a) 9:34 a.m., access to the electrical panel in the activities office storage closet was blocked by miscellaneous items;
b) 10:53 a.m., access to the electrical panel in the second-floor office by the lounge was blocked by miscellaneous items.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on February 7, 2024, at 1:30 p.m., confirmed the listed electrical equipment deficiencies.






 Plan of Correction - To be completed: 02/29/2024

1. Items stored in front of the electrical panel in the activities closet have been removed. Items blocking the electrical panel in second floor office have been removed.
2. The Maintenance Director and/or designee will conduct a visual inspection of all electrical panels to ensure they are not obstructed
3. The Maintenance Director and/or designee will do a visual inspection monthly for three months of all electrical panels and report his finding at the monthly Safety Committee meeting. These findings will be reviewed at the Quality Assurance and Performance Improvement committee meetings.
4. Date of compliance is 2/29/24.


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