Pennsylvania Department of Health
ADVANCED CARE CENTER OF BUTLER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 6 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.


ADVANCED CARE CENTER OF BUTLER - 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 March 6, 2024, it was determined that Advanced Care Center of Butler had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

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

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

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

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

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

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

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

Observations:
Name: - Component: -- - Tag: 0036

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

Findings include:

Document review on March 6, 2024, at 10:22 a.m., revealed the facility lacked an emergency preparedness plan that included annual emergency management training for all staff.

Interview with the maintenance director on March 6, 2024, at 10:22 a.m., confirmed the emergency preparedness plan did not include emergency management training.

Plan of Correction - To be completed: 05/31/2024

The Administrator and the Director of Facilities Management and Environmental Services will coordinate and provide EP annual training for the employees.
The documentation of the annual EP training will be maintained in the EP manual.
The next annual training will be scheduled in advance.
The revised process will be reviewed in the next QAPI committee meeting.

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:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Findings include:

Document review on March 6, 2024, at 10:25 a.m., revealed the facility failed to conduct a full-scale emergency preparedness exercise that was followed by an exercise evaluation and necessary policy changes within the previous year.

Interview with the maintenance supervisor on March 6, 2024, at 10:25 a.m., confirmed the emergency preparedness plan did not include a full-scale emergency preparedness exercise.

Plan of Correction - To be completed: 05/31/2024

The Advanced Care Center of Butler required full evacuation of the facility on Wednesday, March 13, 2024 in relation to a suspected interior fire. All EP procedures were followed. Evaluation by the staff indicated policy changes in the future.
The documentation of the site-specific exercise is in the EP manual for review.
The Administrator and the Director of Facilities and Environmental Services will coordinate the schedule for upcoming Education and community exercises in order to assure timeliness.

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

§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 document review and interview, the facility failed to maintain emergency preparedness guidelines that included emergency and standby power information for one of one emergency preparedness plan.

Findings include:

Document review on March 6, 2024, at 10:28 a.m., revealed the facility emergency preparedness plan lacked a site-specific plan for back-up emergency and standby power.

Interview with the administrator and maintenance technician on March 6, 2024, at 10:28 a.m., confirmed the facility's emergency preparedness plan lacked emergency and standby power information.

Plan of Correction - To be completed: 05/31/2024

The Administrator and the Director of Facilities Management and Environmental Services will develop the policy for emergency and standby response.
The policy will direct for a full facility evacuation to sites indicated in the emergency preparedness plan in the case of emergency back-up power failure.
The Director of Facilities Management and Environmental Services and the Administrator will provide education to all ACC staff regarding the new policy.
The policy will be reviewed in the next QAPI committee meeting.

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

Facility ID 50690201
Component 01
Main Building

Based on a Recertification Survey completed on March 6, 2024, it was determined that Advanced Care Center of Butler was not in compliance with the requirements of the Life Safety Code for a new 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 II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to meet emergency lighting requirements for one of one facility.

Findings include:

Document review on March 6, 2024, at 10:22 a.m., revealed the facility was unable to provide documentation for monthly thirty-second testing of the back-up emergency lighting for seven of twelve months.

Interview with the director of facilities on March 6, 2024, at 10:22 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 05/31/2024

The Director of Facilities Management and Environmental Services or designee will assure a maintenance work order will be generated in the preventative maintenance software program for the annual and 30 second monthly light tests to be completed.
The Director of Facilities Management and Environmental Services will educate the maintenance staff regarding the testing protocols and the software management for printing and filing documents to support the completed inspections.
The Administrator will audit the completed reports on a monthly basis x three months to confirm documentation is completed and filed and then quarterly.
The process will be reviewed in the next QAPI committee meeting.

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 NEW
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
18.2.10.1

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

Based on document review and interview, the facility failed to meet exit signage requirements for one of one facility.

Findings include:

Document review on March 6, 2024, at 10:02 a.m., revealed the facility was unable to provide monthly exit sign inspection documentation.

Interview with the director of facilities on March 6, 2024, at 10:02 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 05/05/2024

The Director of Facilities Management and Environmental Services or designee will assure a maintenance work order will be generated in the preventative maintenance software for the monthly exit sign inspections.
The Director of Facilities Management and Environmental Services will educate the maintenance staff regarding the testing protocols and the software management for printing and filing documents to support the completed inspections.
The Administrator will audit the completed reports on a monthly basis x three months to confirm documentation is completed and filed and then quarterly.
The process will be reviewed in the next QAPI committee meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

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 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to meet fire alarm system testing and maintenance requirements for one of two semi-annual requirements.

Findings include:

Document review on March 6, 2024, at 10:33 a.m., revealed the facility was unable to provide documentation for the semi-annual visual fire alarm system inspection.

Interview with the director of facilities on March 6, 2024, at 10:02 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 05/05/2024

The Director of Facilities Management and Environmental Services will assure a maintenance work order will be generated in the preventative maintenance software for the semi-annual visual fire alarm system inspection.
The Director of Facilities Management and Environmental Services will assure the semi-annual visual fire alarm system inspection is scheduled.
The Director of Facilities Management and Environmental Services will educate the maintenance staff regarding the protocol for visual fire alarm inspection and the software management for the printing and filing of documents to support the completed inspections.
The Administrator will audit the completed reports on a monthly basis x 3 months to confirm documentation is completed and filed and then quarterly.
This process will be reviewed in the next QAPI committee meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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

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 - Component: 01 - Tag: 0353

Based on observation and interview, the facility failed to maintain fire sprinkler system maintenance in one of over twenty rooms.
Findings include:
Observation on March 6, 2024, at 11:07 a.m., revealed the main floor kitchen dry storage room had boxes and products located within eighteen inches of the sprinkler head, possibly restricting the flow of the automatic sprinkler in the event of an emergency.
Interview with the maintenance technician on March 6, 2024, at 11:07 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 05/31/2024

The Director of Facilities Management and Environmental Services of designee will inspect the building to assure there is no storage to possibly restrict the flow of the automatic sprinkler and document findings.
The findings will be reported to the Administrator.
The cited area in the kitchen was immediately corrected.
The Director of Facilities Management and Environmental Services or designee will perform weekly inspections of the facility during room checks to assure no further issues with storage and blockage of sprinkler heads. The monthly inspections will be provided to the Administrator when completed.
Documentation of the inspections will be filed in the Emergency Preparedness Policy.
The new process will be reviewed in the next QAPI committee meeting.

NFPA 101 STANDARD Fire Drills:

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.
18.7.1.4 through 18.7.1.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for one of four quarters.

Findings include:

Document review on March 6, 2024, at 9:40 a.m., revealed the facility was unable to provide documentation for the first shift, fourth quarter fire alarm drill.

Interview with the director of facilities on March 6, 2024, at 9:40 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 05/31/2024

The Director of Facilities Management and Environmental Services will meet with the Administrator for education regarding the scheduling of fire drills quarterly.
The Director of Facilities or designee will document the fire drill and provide the report to the Administrator when completed.
The Administrator will review the documentation for accuracy and completeness and have the report filed in the manual monthly.
The process will be reviewed in the next QAPI committee meeting.

NFPA 101 STANDARD Electrical Systems - Other:

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.

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 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain electrical systems for one of over five mechanical rooms.
Findings include:
Observation on March 6, 2024, at 11:55 a.m., revealed the mechanical room next to the oxygen room had paint and boxes stored in front of the electrical panels.

Interview with the maintenance supervisor on March 6, 2024, at 11:55 a.m., confirmed the items were blocking the electrical panels at the time of the survey.

Plan of Correction - To be completed: 05/05/2024

The Director of Facilities Management and Environmental Services or designee will round the facility on a weekly basis to assure the electrical room and electrical panels remain clear of unnecessary storage.
The Director of Facilities Management and Environmental Services or Designee will provide documentation to the Administrator following the monthly inspection for review and filing in the manual.

NFPA 101 STANDARD Electrical Systems - Receptacles:

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 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles in one of over twenty rooms.

Findings include:

Observation on March 6, 2024, at 10:51 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of a sink in the Avalon wing clean utility room.

Interview with the facilities manager on March 6, 2024, at 10:51 a.m., confirmed the electrical outlet deficiency.

Plan of Correction - To be completed: 05/31/2024

The Director of Facilities Management and Environmental Services will produce a work order in the maintenance software for a ground fault circuit interrupter (GFCI) receptacle in the Avalon wing clean utility room.
The Director of Facilities Management and Environmental Services will provide the Administrator a copy of the work order.
The Director of Facilities Management and Environmental or designee will inspect the full facility for the need for additional ground fault circuit interrupter receptacles and provide the documentation of the inspection to the Administrator.
The Director of Facilities Management and Environmental Services or designee will inspect during annual receptacle testing.
The process will be reviewed in the next QAPI committee meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to meet essential electric system requirements for one of one facility.

Findings include:

Document review on March 6, 2024, between 10:08 and 10:10 a.m., revealed the facility had the following deficiencies:
A. (10:08 a.m.) Monthly electrolyte levels for the generator battery were undocumented;
B. (10:10 a.m.) Annual fuel sample, taken December 4, 2023, was above limits stability and failed particle count. The facility was unable to provide corrective documentation for the fuel.

Interview with the director of facilities on March 6, 2024, at 10:10 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 05/05/2024

The Director of Facilities Management and Environmental Services will submit a work order for an immediate inspection of the generator electrolyte levels and provide the documentation to the Administrator when completed.
The Director of Facilities Management and Environmental Services will submit a work order for the fuel in the generator to be scrubbed and the report provided to the Administrator for the manual.
The Director of Facilities Management and Environment Services will obtain the documentation of electrolyte inspections and present them to the Administrator monthly.
The Administrator will review documentation of the inspections as being complete and for any issues that may need to be immediately addressed.
The revised process will be reviewed in the next QAPI committee meeting.

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