Pennsylvania Department of Health
HILLTOP HEIGHTS HEALTH & REHAB CENTER
Building Inspection Results

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HILLTOP HEIGHTS HEALTH & REHAB CENTER
Inspection Results For:

There are  37 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.
HILLTOP HEIGHTS HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 24, 2024, it was determined that Hilltop Heights Health and Rehab Center was not in compliance with the requirements of 42 CFR 483.73.






 Plan of Correction:


482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power: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.
§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, for six of the past 12 months, affecting the entire facility.

Findings include:

1. Review of documentation on January 24, 2024, at 11:30 a.m., revealed the facility failed to provide documentation at the time of the survey for the following required emergency generator testing for July through December 2023:

a) weekly battery voltage testing;
b) monthly battery conductance testing;
c) monthly automatic transfer switch testing.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.





 Plan of Correction - To be completed: 02/26/2024

E-0041 Hospital CAH and LT Emergency Power
1. The facility is unable to correct the missed generator tests retrospectively however, the maintenance director and assistant will complete the weekly and monthly required testing.
2. The generator testing requirements (weekly, monthly, and annual) will be scheduled in advance by the maintenance director or designee for each month in 2024 with regard to the regulation.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The generator test completion and results will be reviewed by the maintenance director or designee in the monthly QAPI meetings.

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

Facility ID# 380502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 24, 2024, it was determined that Hilltop Heights Health and Rehab Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90 (a).

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



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined that the facility failed to maintain an unobstructed means of egress in three instances, affecting two of five smoke compartments.

Findings include:

1. Observation on January 24, 2024, revealed the following means of egress deficiencies:

a) 9:18 a.m., the supply storage room by central supply was overcrowded with storage blocking the aisleways which impeded the means of egress;
b) 9:20 a.m., half of the width of the central supply hallway was being used for storage of miscellaneous items impeding the means of egress path to the exit door;
c) 10:50 a.m., the facility failed to ensure there was an unobstructed means of egress to a common way. The sidewalk and landing at the East hallway exit door were covered with several inches of snow.
Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed means of egress deficiencies.







 Plan of Correction - To be completed: 02/26/2024

K-0211 Means of Egress
1. The containers blocking the aisles in the storage rooms by central supply and the equipment blocking part of the central supply hallway were removed by the by the maintenance director and assistant immediately following the survey. The snow was removed by the maintenance director and assistant from the two exits that did not meet with egress regulation.
2. An initial audit of all egress areas in the facility was conducted to determine that all areas met the regulation.
3. The administrator will educate the department managers on the regulation.
4. A weekly audit of the egress areas will be completed by the maintenance director or designee for 3 weeks. The audit results will be reviewed by the maintenance director or designee in the monthly QAPI meetings.

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

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of five smoke compartments.

Findings include:

1. Observation on January 24, 2024, at 9:29 a.m., revealed the facility failed to maintain the required one-hour fire rating in hazardous area enclosure locations. The door to the soiled side of the laundry would not self-close and latch in its frame when tested.


Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure deficiency.





 Plan of Correction - To be completed: 02/26/2024

K0321 Hazardous Areas - Enclosure
1. The door latch to the soiled side of the laundry will be repaired to self-close by the maintenance director or supervisor.
2. An audit of the self-closure doors in the hazardous areas of the facility will be conducted and any identified problems will be repaired or replaced by the maintenance director or designee.
3. The administrator will educate the department managers on the regulation.
4. A weekly audit of self-closure doors in the hazardous areas will be completed by the maintenance director or designee for 3 weeks. The audit results will be reviewed by the maintenance director or designee in the monthly QAPI meetings.

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




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on observation and interview the facility failed to install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of five smoke compartments. In accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1.

Findings include:

1. Observation on January 24, 2024, at 10:01 a.m., revealed the wheeled gas-fired oven/cook-top located on the cooking line in the kitchen was not equipped with an approved method that would ensure that the appliance was returned to an approved design location under the kitchen hood extinguishing system after it had been moved for maintenance and cleaning.


Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed kitchen hood extinguishing system deficiency.






 Plan of Correction - To be completed: 02/26/2024

K-0324 Cooking Facilities
1. The equipment to maintain the proper placement of the oven/cook top was ordered and will be installed once received.
2. There are no other cook tops to check in the kitchen.
3. The administrator will educate the Maintenance Director, Assistant Maintenance Director, and the Dietary Director on the regulation.
4. The results of the Life Safety Survey and progress of the plan of correction will be reviewed in the monthly QAPI 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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting two of five smoke compartments.

Findings include:

1. Observation on January 24, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:11 a.m., an inspection above the ceiling by the clean linen laundry room door revealed pipes were lying on top of the sprinkler branch line in the service hallway;
b) 9:12 a.m., an inspection above the ceiling by the soiled linen laundry room door revealed MC cables were lying on top of the sprinkler branch line in the service hallway;
c) 10:15 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 ceiling of the north hall equipment room by the nurse station.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.








 Plan of Correction - To be completed: 02/26/2024

K-353 Sprinkler System – Maintenance and Testing
1. The pipes lying on top of the sprinkler branch line in the clean linen laundry room were adjusted in height so they are not touching the branch line. The MC cables lying on top of the sprinkler branch lines in the service hallway were adjusted in height so they are not touching the cables. The multiple unsealed penetrations in the ceiling of the north hall equipment room by the nurse station were repaired.
2. A random audit of 5 other areas in the ceiling will be checked by the maintenance director of designee for unsealed penetrations in the ceiling and cables lying on top of the sprinkler branch lines.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The results of the Life Safety Survey audits and education will be reviewed in the monthly QAPI meeting for 2 months.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of five smoke compartments.

Findings include:

1. Observation on January 24, 2024, at 10:27 a.m., revealed an unsealed cooling pipe penetration in the west hall smoke barrier wall, above the ceiling, at the smoke barrier doors by the soiled utility room.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed smoke barrier wall deficiency.


 Plan of Correction - To be completed: 02/26/2024

K-0372 Subdivision of Building Spaces – Smoke Barrier
1. The unsealed cooling pipe penetration in the west hall smoke barrier wall, above the ceiling, at the smoke barrier doors by the soiled utility room will be repaired with a UL approved penetration fire stop system by the maintenance director or designee.
2. A random audit of 5 other areas in the ceiling will be checked by the maintenance director or designee for unsealed penetrations in the ceiling.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The results of the Life Safety Survey audits and education will be reviewed in the monthly QAPI meeting for 2 months.

NFPA 101 STANDARD Fire Drills:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Fire 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 January 24, 2024, at 11:30 a.m., revealed the facility lacked documentation for a first-quarter fire drill for the third shift.


Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed fire drill testing deficiency.


 Plan of Correction - To be completed: 02/26/2024

K-0712 Fire Drills
1. The facility is unable to correct a missed fire drill retrospectively from the 3rd quarter that involved a previous manager however, the fire drills since that time have been completed according to the regulation and the January 2024 fire drill was completed by the maintenance director and assistant.
2. The fire drills will be scheduled in advance by the maintenance director or designee for each month in 2024 with regard to the regulation.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The fire drill results will be reviewed by the maintenance director or designee in the monthly QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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 the two-hour fire rating of the emergency generator enclosure for one of one emergency generators, affecting the entire facility. Installation shale be in accordance with NFPA 101, 8.2.3 and NFP 110, 7.2.1.1

Findings include:

1. Observation on January 24, 2024, at 9:37 a.m., revealed the ceiling of the emergency generator room was not sealed around the emergency generator exhaust stack.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed emergency generator enclosure deficiency.






 Plan of Correction - To be completed: 02/26/2024

K-0911 Electrical Systems – Other
1. The ceiling penetration of the emergency generator exhaust stack will be sealed by the maintenance director of designee.
2. There is only one generator room so there are no others to check.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The results of the Life Safety Survey and progress of the plan of correction will be reviewed in the monthly QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Receptacles:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

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

Findings include:

1. Observation on January 24, 2024, at 9:53 a.m., revealed there was an electrical receptacle within six feet of a sink, that was not GFCI protected, in the dining room serving area of the kitchen.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed electrical receptacle deficiency.


 Plan of Correction - To be completed: 02/26/2024

K-0912 Electrical Systems – Receptacles
1. The electrical receptacle in the dining room serving area in the kitchen was replaced with a GCIF receptacle by the maintenance director or designee.
2. The receptacles in the resident rooms and bathrooms, public restrooms, kitchen and activity room will be audit for having a GCFI receptacle by the maintenance director or designee.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The results of the Life Safety Survey audits and education will be reviewed in the monthly QAPI meeting for 2 months.

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

Findings include:

1. Documentation review on January 24, 2024, at 11:30 a.m., revealed the facility failed to perform the required annual tension and continuity test of non-hospital grade electrical receptacles in patient sleeping rooms. The most recent testing/inspection of non-hospital grade electrical receptacles in patient sleeping rooms was performed on October 10, 2022.


Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed electrical receptacle testing/inspection deficiency.







 Plan of Correction - To be completed: 02/26/2024

K-0914 Electrical Systems – Maintenance and Testing
1. The electrical receptacles will be tested according to the regulation requirements in all resident rooms by the maintenance director or designee. Any problems found will be repaired or replaced.
2. The administrator or designee will audit that all resident rooms have been tested and check that any needed repairs or replacements have been completed.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. The results of the Life Safety Survey audits and education will be reviewed in the monthly QAPI meeting for 2 months.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, for six of the past 12 months, affecting the entire facility.

Findings include:

1. Review of documentation on January 24, 2024, at 11:30 a.m., revealed the facility failed to provide documentation at the time of the survey for the following required emergency generator testing for July through December 2024:

a) weekly battery voltage testing;
b) monthly battery conductance testing;
c) monthly automatic transfer switch testing.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.




 Plan of Correction - To be completed: 02/26/2024

K-0918 Electrical Systems – Essential Electrical System
5. The facility is unable to correct the missed generator tests retrospectively however, the maintenance director and assistant will complete the weekly and monthly required testing.
6. The generator testing requirements (weekly, monthly, and annual) will be scheduled in advance by the maintenance director or designee for each month in 2024 with regard to the regulation.
7. The administrator will educate the Maintenance Director and Assistant on the regulation.
8. The generator test completion and results will be reviewed by the maintenance director or designee in the monthly QAPI meetings.

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 one instance, affecting one of five smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on January 24, 2024, at 9:19 a.m., revealed that miscellaneous storage blocked access to the electrical panel in the storage room by central supply.


Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed electrical equipment deficiency.






 Plan of Correction - To be completed: 02/26/2024

K-0919 Electrical Equipment – Other
1. The storage containers blocking the electrical panel were removed immediately by the maintenance director.
2. An audit will be conducted of all electrical panels throughout the facility to make sure there is nothing blocking them.
3. The administrator will educate the Maintenance Director and Assistant on the regulation.
4. A weekly audit of the electrical panels for clearance will be conducted by the maintenance director or designee and the results will be reviewed in the monthly QAPI meetings for 2 months.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of five smoke compartments.

Findings include:

1. Observation on January 24, 2024, at 9:47 a.m., revealed a refrigerator was plugged into a power strip in the payroll office.


Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed electrical wiring systems and equipment deficiency.






 Plan of Correction - To be completed: 02/26/2024

K-0920 Electrical Equipment – Power Cords and Extensions
1. The extension cord was removed immediately by the maintenance director.
2. An audit will be conducted of all offices, conference rooms, and resident rooms throughout the facility to make sure there are no extension cords (with the exception of computers with allowing power strips).
3. The administrator will educate the management team members on the regulation.
4. A weekly audit of 10 rooms in the facility will be completed by the maintenance director or designee for 3 weeks. The audits and results will be reviewed by the maintenance director or designee in the monthly QAPI meetings for 2 months.


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