Pennsylvania Department of Health
HERMITAGE NURSING AND REHABILITATION
Building Inspection Results

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HERMITAGE NURSING AND REHABILITATION
Inspection Results For:

There are  41 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.
HERMITAGE NURSING AND REHABILITATION - 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 December 29, 2023, it was determined that Hermitage Nursing and Rehabilitation was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

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

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

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

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

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


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

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

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

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

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

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

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, the facility failed to full-scale exercise, test, evaluate, and table top exercise for one of one Emergency Preparedness Plan.

Findings include:

Document review on December 29, 2023, at 8:00 a.m., revealed the facility lacked documentation for an annual table top exercise, along with the required community based, full-scale exercise at the time of the survey.

Interview with the maintenance director and administrator on December 29, 2023, at 8:00 a.m., confirmed the lack of documentation.






 Plan of Correction - To be completed: 02/13/2024

483.73 (d) (2) EMERGENCY PLAN TESTING

0039

Facility will hold a Mock Disaster Drill that is facility based and functional in exercise. The Mock Disaster will then conclude with a Table Top Exercise or Workshop. Facility Administrator and the Director of Maintenance will lead the drills and workshop that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problems that is designed to challenge the emergency plan. All drills and tabletop exercises will be documented reviewed and placed within our emergency preparedness binder. The Emergency Plan will be discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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


Facility ID #140702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on December 29, 2023, it was determined that Hermitage Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

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





 Plan of Correction:


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, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:

Document review on December 29, 2023, at 8:30 a.m., revealed the facility could not provide documentation for a fire alarm semi-annual visual inspection.

Interview with the maintenance director on December 29, 2023, at 8:30 a.m., confirmed the documentation could not be provided.







 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD FIRE ALARM SYSTEM – TESTING AND MAINTENANCE
Main Building 01 Component 01

0345

Facility maintenance director will formulate a spreadsheet to better track fire alarm system inspection to ensure all maintenance and testing is 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. All documentation will be reviewed and placed within our life safety binder located in the maintenance director's office. Records of system acceptance, maintenance and testing are readily available. The fire alarm system inspection will also be discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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 document review and interview, the facility failed to maintain the sprinkler system, affecting the entire building.

Findings include:

Document review on December 29, 2023, at 10:00 a.m., revealed the first and second quarter sprinkler inspection reports were unavailable at the time of the survey.

Interview with the maintenance director on December 29, 2023, at 10:00 a.m., confirmed the sprinkler documentation was missing.




 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD SPRINKLER SYSTEM – MAINTENANCE AND TESTING
Main Building 01 Component 01

0353

Facility maintenance director will formulate a spreadsheet to better track Sprinkler System Testing Inspection. The Sprinkler Testing will include testing the automatic sprinkler and standpipe systems. These will be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, testing and maintaining of water based Fire Protections Systems. All records of maintenance, inspections and testing will be secured in the maintenance director's office and readily available upon request with sprinkler system last "checked by" and "water system supply source". All findings and documentation will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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

Based on document review and interview, the facility failed to maintain smoke and fire barrier doors in three of three building components.

Findings include:

Document review on December 29, 2023, at 9:45 a.m., revealed the facility lacked documentation for an annual fire/smoke door inspection within the last year.

Interview with the maintenance director on December 29, 2023, at 9:45 a.m., confirmed the annual fire/smoke door inspection documentation was unavailable at the time of the survey.





 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD MAINTENANCE, INSPECTION & TESTING – DOORS
Main Building 01 Component 02

0761

Facility failed to maintain smoke and fire barrier door documentation for annual fire / smoke door inspection within the last year. Observation was noted facility had certified Door Inspections, Testing and Maintenance inspector in the facility to inspect all Doors, Fire Door Assemblies. Individual performing the door inspections and testing possesses the knowledge, training and experiences that demonstrates the proper ability. All in accordance with NFPA 80, Standard for Fire Doors and other Opening Protectives. Written records of the inspection and testing are maintained and available for review upon request in the maintenance director's office. All findings and documentation will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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

Based on document review and interview, the facility failed to ensure electrical receptacles were tested at patient bed locations within the facility.

Findings include:

Document review on December 29, 2023, at 10:13 a.m., revealed the facility could not provide documentation that electrical receptacles in patient care rooms were tested for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. Visual inspection of physical integrity;
b. Correct polarity of the hot and neutral connections;
c. Retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Interview with the maintenance director on December 29, 2023, at 10:13 a.m., confirmed the missing documentation.







 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD ELECTRICAL SYSTEMS- MAINTENANCE AND TESTING
Main Building 01 Component 03

0914

Facility failed to provide documentation that electrical receptacles in patient care rooms were tested. This includes a visual inspection of physical integrity, correct polarity of the hot and neutral connections, and retention force of the grounding blade. Observation was noted and deficiency corrected. Written records of the inspection and testing is available upon request in the maintenance directors office. All findings and documentation associated with testing, repairs and or modifications will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #140702
Component 02
Administrative Building

Based on a Medicare/Medicaid Recertification Survey completed on December 29, 2023, it was determined that Hermitage Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected, wood frame building, that is fully sprinklered.




 Plan of Correction:


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: BUILDING 02 - Component: 02 - Tag: 0345

Based on document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:

Document review on December 29, 2023, at 8:30 a.m., revealed the facility could not provide documentation for the fire alarm semi-annual visual inspection.

Interview with the maintenance director on December 29, 2023, at 8:30 a.m., confirmed the documentation could not be provided.




 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD FIRE ALARM SYSTEM – TESTING AND MAINTENANCE
Main Building 01 Component 03

0345

Facility maintenance director will formulate a spreadsheet to better track fire alarm system inspection to ensure all maintenance and testing is 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. All documentation will be reviewed and placed within our life safety binder located in the maintenance director's office. Records of system acceptance, maintenance and testing are readily available. The fire alarm system inspection will also be discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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: BUILDING 02 - Component: 02 - Tag: 0353

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

Findings include:

Document review on December 29, 2023, at 10:00 a.m., revealed the first and second quarter sprinkler inspection reports were unavailable at the time of the survey.

Interview with the maintenance director on December 29, 2023, at 10:00 a.m., confirmed the sprinkler documentation was missing.




 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD SPRINKLER SYSTEM – MAINTENANCE AND TESTING
Main Building 01 Component 01

0353

Facility maintenance director will formulate a spreadsheet to better track Sprinkler System Testing Inspection. The Sprinkler Testing will include testing the automatic sprinkler and standpipe systems. These will be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, testing and maintaining of water based Fire Protections Systems. All records of maintenance, inspections and testing will be secured in the maintenance director's office and readily available upon request with sprinkler system last "checked by" and "water system supply source". All findings and documentation will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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

Based on document review and interview, the facility failed to maintain smoke and fire barrier doors in three of three building components.

Findings include:

Document review on December 29, 2023, at 9:45 a.m., revealed the facility lacked documentation that an annual fire/smoke door inspection was performed within the last year.

Interview with the maintenance director on December 29, 2023, at 9:45 a.m., confirmed the annual fire/smoke door inspection documentation was unavailable at the time of the survey.





 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD MAINTENANCE, INSPECTION & TESTING – DOORS
Main Building 01 Component 02

0761

Facility failed to maintain smoke and fire barrier door documentation for annual fire / smoke door inspection within the last year. Observation was noted facility had certified Door Inspections, Testing and Maintenance inspector in the facility to inspect all Doors, Fire Door Assemblies. Individual performing the door inspections and testing possesses the knowledge, training and experiences that demonstrates the proper ability. All in accordance with NFPA 80, Standard for Fire Doors and other Opening Protectives. Written records of the inspection and testing are maintained and available for review upon request in the maintenance director's office. All findings and documentation will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000


Facility ID #140702
Component 03
Dementia Building

Based on a Medicare/Medicaid Recertification Survey completed on December 29, 2023, it was determined that Hermitage Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected, wood frame building, that is fully sprinklered.




 Plan of Correction:


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: BUILDING 03 - Component: 03 - Tag: 0345

Based on document review and interview, the facility failed to ensure the fire alarm system was inspected at required intervals, affecting the entire facility.
Findings include:

Document review on December 29, 2023, at 8:30 a.m., revealed the facility could not provide documentation for a fire alarm semi-annual visual inspection.

Interview with the maintenance director on December 29, 2023, at 8:30 a.m., confirmed the documentation could not be provided.




 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD FIRE ALARM SYSTEM – TESTING AND MAINTENANCE
Main Building 01 Component 03

0345

Facility maintenance director will formulate a spreadsheet to better track fire alarm system inspection to ensure all maintenance and testing is 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. All documentation will be reviewed and placed within our life safety binder located in the maintenance director's office. Records of system acceptance, maintenance and testing are readily available. The fire alarm system inspection will also be discussed during the facilities Quality Assurance and Performance Improvement Meeting.

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: BUILDING 03 - Component: 03 - Tag: 0353

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

Findings include:

Document review on December 29, 2023, at 10:00 a.m., revealed the first and second quarter sprinkler inspection reports were unavailable at the time of the survey.

Interview with the maintenance director on December 29, 2023, at 10:00 a.m., confirmed the sprinkler documentation was missing.




 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD SPRINKLER SYSTEM – MAINTENANCE AND TESTING
Main Building 01 Component 01

0353

Facility maintenance director will formulate a spreadsheet to better track Sprinkler System Testing Inspection. The Sprinkler Testing will include testing the automatic sprinkler and standpipe systems. These will be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, testing and maintaining of water based Fire Protections Systems. All records of maintenance, inspections and testing will be secured in the maintenance director's office and readily available upon request with sprinkler system last "checked by" and "water system supply source". All findings and documentation will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0761

Based on document review and interview, the facility failed to maintain smoke and fire barrier doors in three of three building components.

Findings include:

Document review on December 29, 2023, at 9:45 a.m., revealed the facility lacked documentation that an annual fire/smoke door inspection was performed within the last year.

Interview with the maintenance director on December 29, 2023, at 9:45 a.m., confirmed the annual fire/smoke door inspection documentation was unavailable at the time of the survey.





 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD MAINTENANCE, INSPECTION & TESTING – DOORS
Main Building 01 Component 02

0761

Facility failed to maintain smoke and fire barrier door documentation for annual fire / smoke door inspection within the last year. Observation was noted facility had certified Door Inspections, Testing and Maintenance inspector in the facility to inspect all Doors, Fire Door Assemblies. Individual performing the door inspections and testing possesses the knowledge, training and experiences that demonstrates the proper ability. All in accordance with NFPA 80, Standard for Fire Doors and other Opening Protectives. Written records of the inspection and testing are maintained and available for review upon request in the maintenance director's office. All findings and documentation will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0914

Based on document review and interview, the facility failed to ensure electrical receptacles were tested at patient bed locations within the facility.

Findings include:

Document review on December 29, 2023, at 10:13 a.m., revealed the facility could not provide documentation that electrical receptacles in patient care rooms were tested for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. Visual inspection of physical integrity;
b. Correct polarity of the hot and neutral connections;
c. Retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Interview with the maintenance director on December 29, 2023, at 10:13 a.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 02/13/2024

NFPA 101 STANDARD ELECTRICAL SYSTEMS- MAINTENANCE AND TESTING
Main Building 01 Component 03

0914

Facility failed to provide documentation that electrical receptacles in patient care rooms were tested. This includes a visual inspection of physical integrity, correct polarity of the hot and neutral connections, and retention force of the grounding blade. Observation was noted and deficiency corrected. Written records of the inspection and testing is available upon request in the maintenance directors office. All findings and documentation associated with testing, repairs and or modifications will be provided, reviewed discussed during the facilities Quality Assurance and Performance Improvement Meeting.


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