Pennsylvania Department of Health
BRIGHTON REHABILITATION AND WELLNESS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 65 surveys for this facility. Please select a date to view the survey results.

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BRIGHTON REHABILITATION AND WELLNESS 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 March 4, 2024, it was determined that Brighton Rehabilitation and Wellness Center 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, it was determined the facility failed to meet emergency preparation testing requirements in the emergency preparedness plan.

Findings include:

1. Documentation review on March 4, 2024, at 8:40 a.m., reveled the facility failed to meet the annual requirements for a community-based, full-scale exercise.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the missing documentation for a full-scale exercise.

Plan of Correction - To be completed: 04/15/2024

0039CE: Based on observation, it was determined the facility failed to conduct a facility-base functional exercise.
1. The facility held a community-based full-scale exercise of a mock-disaster drill / table top exercise including all unit directors and administrative directors.
2. The Maintenance Director audited for completion of annual community-based full-scale exercise.
3. The Maintenance Director will be re-in-serviced by the Licensed Administrator on the requirement and facility policy to ensure an annual community-based full-scale exercise occurs.
4. The Maintenance Director or designee will review annually to ensure completion of the plan of correction and report findings to the QA to ensure regulatory compliance.

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 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.

§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 in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on March 4, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The annual 90 minute load bank;
b) The annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.

Plan of Correction - To be completed: 04/15/2024

0041F: Based on observation, it was determined the facility failed to maintain the emergency generator 2 two instances.
1. The annual 90-minute load bank test was completed. The annual fuel test quality was completed.
2. The Maintenance Director audited for completion of annual 90-minute load bank test and annual fuel test quality.
3. The Maintenance Director will be re-in-serviced by the Licensed Administrator on the requirement and facility policy to ensure an annual 90-minute load bank test and annual fuel test quality are completed.
4. The Maintenance Director or designee will review annually to ensure completion of the plan of correction and report findings to the QA to ensure regulatory compliance.

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

Facility ID# 020802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 4-6, 2024, it was determined that Brighton Rehabilitation and Wellness 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 six-story, Type II (222), fire resistive building, with a basement and a penthouse, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating that separate the main building from the grove, on one of two floors.

Findings include:

1. Observation on March 6, at 9:00 a.m., revealed the door on the second floor, seperating the Grove from the main building failed to fully close and latch in the frame.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the deficiencies with the doors in the two-hour fire rated occupancy separation wall.

Plan of Correction - To be completed: 04/15/2024

0131E: Based on observation and interview, it was determined the facility failed to maintain the two-hour fire-resistance rating that separates the main building from the annex building, on two of two floors.
1. The Door on the second floor of the Grove Building were repaired so that they can fully close and latch to their frame.
2. The Maintenance Director audited to ensure that the doors were fully closed and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on how to inspect and report a door not closing so that the door technician can repair it.
4. Doors on the Grove Building will be audited 3 times a week for 3 weeks; then 2 times a month for 2 months, and all findings will be reported to Quality Assurance Committee to ensure regulatory compliance.

NFPA 101 STANDARD Means of Egress - General:

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.

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 the facility failed to maintain means of egress to be free of all obstructions for full use in case of an emergency, in one instance, affecting one of 26 smoke compartments.

Findings include:

1. Observation on March 4, 2024, at 9:50 a.m., revealed there was a padlock and hasp on the door to the supply area in the main laundry.

Interview with the Facility Administrator and the Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the means of egress deficiency.

Plan of Correction - To be completed: 04/15/2024

0211D: Based on observation, it was determined the facility failed to maintain a continuously unobstructed path of egress from an exit door.
1. The padlock and hasp on the door to the supply area in the main laundry was removed.
2. The Maintenance Director audited doors in the laundry area and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on how to inspect and report a locked door so that the door technician can unlock it.
4. The Main Laundry doors will be audited 3 times a week for 3 weeks; than2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain the self-closing doors in one instance, affecting one of 26 smoke compartments.

Findings include:

1. Observation on March 4, 2024, at 10:18 a.m., revealed the door to the housekeeping closet by the restroom failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the above listed self-closing door deficiency.

Plan of Correction - To be completed: 04/15/2024

0223D: Based on observation, it was determined the facility failed to maintain a self-closing door in one instance.
1. The door to the housekeeping closet by the restroom was repaired to latch.
2. The Maintenance Director audited the housekeeping closet door and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on how to inspect and report a door not latching so that the door technician can repair it.
4. The housekeeping closet door will be audited 3 times a week for 3 weeks; than2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 areas in three instances, affecting three of 26 smoke compartments.

Findings include:

1. Observation on March 4, 2024, at 9:50 a.m., revealed the door to the Grove 1 soiled utility room failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the hazardous enclosure deficiency.

2. Observation on March 5, 2024, at 10:15 a.m., revealed the door to the 5 main electrical panel room failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the hazardous enclosure deficiency.

3. Observation on March 6, 2024, revealed the following hazardous area enclosure deficiencies:
a) 8:45 a.m., the door to the kitchen across the hall from admissions, failed to latch when tested;
b) 9:18 a.m., the door to the kitchen across the hall from the chapel, failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the hazardous enclosure deficiencies.

Plan of Correction - To be completed: 04/15/2024

0321E: Based on observation, it was determined the facility failed to maintain hazardous area enclosures.
1. The door to the Grove 1 soiled utility room was repaired to latch. The door to the 5 main electrical panel was repaired to latch. The door to the kitchen across the hall from the admissions office was repaired to latch. The door to the kitchen across the hall from the chapel was repaired to latch.
2. The Maintenance Director audited all locations that failed to latch and maintain the hazardous area and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director how to maintain doors and to ensure there positive latching.
4. Failed locations will be audited 3 times a week for 3 weeks; than2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting eight of 26 smoke compartments.

Findings include:

1. Observation on March 4, 2024, revealed the following deficiencies that would prevent proper operation of the automatic sprinkler system:

a) 9:45 a.m., there was a missing ceiling tile in the beauty salon room in the basement;
b) 9:50 a.m., there were multiple ceiling tiles missing in the basement breakroom.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

2. Observation on March 5, 2024, revealed the following deficiencies that would prevent proper operation of the automatic sprinkler system:

a) 9:05 a.m., there was flex tubing resting on the sprinkler line above the ceiling next to the 4 Main soiled utility closet;
b) 9:14 a.m., there was flex tubing resting on the sprinkler line above the ceiling in the 4 Main crossover;
c) 9:17 a.m., there was a a gap greater than 1/8" inch in the ceiling tile in 5 Main's fire blanket closet;
d) 9:40 a.m., there was flex tubing resting on the sprinkler line above the ceiling on 4 East by the west smoke doors;
e) 10:20 a.m., there were missing ceiling tiles in the 4 Main crossover;
f) 10:30 a.m., there was a a gap greater than 1/8" inch in the ceiling tile of 4 East janitor closet.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/15/2024

0353E: Based on observation, it was determined the facility failed to maintain the automatic sprinkler system in 8 instances.
1. The ceiling tiles in the beauty salon and breakroom were replaced. The flex tubing on resting on the sprinkler line next to 4 main soiled utility closet and 4 main crossover and 4 east by west smoke door was removed. The gaps greater than 1/8" in ceiling tiles by 5 main janitors closer and 4 east janitor closet was repaired. Maintenance replaced the multiple missing ceiling tiles and patched all gaps with Fire Caulking that were exposed in the firewalls.
2. The Maintenance Director audited those locations to ensure all corrections were made to ensure gaps are sealed and no tubing is resting on the sprinkler line.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors for three of more than 50 corridor doors.

Findings include:

1. Observation on March 6, 2024, revealed the following corridor doors would not close and latch when tested:

a) 10:33 a.m., Grove 2 resident room 201;
b) 10:36 a.m., Grove 2 resident room 205.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 04/15/2024

0363E: Based on observation, it was determined the facility failed to maintain corridor doors in four instances.
1. The doors to Grove 2 resident room 201 and 205 were repaired to close and latch to their frames.
2. The Maintenance Director audited the Grove 2 doors and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on reporting doors that do not close and latch to their frame to ensure timely repairs.
4. Those locations will be audited 2 times a week for 3 weeks; then 2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting eight of 26 smoke compartments.

Findings include:

1. Observation on March 5, 2024, revealed the following smoke barrier door deficiencies:

a) 10:42 a.m., there was an excessive gap between the meeting edges of the smoke doors, in 3 Main solarium, that would not resist the passage of smoke;
b) 10:47 a.m., there was an excessive gap between the meeting edges of the smoke doors, in 3 Main on the North side, that would not resist the passage of smoke;
c) 11:00 a.m., there was an excessive gap between the meeting edges of the smoke doors, in 2 Main solarium, that would not resist the passage of smoke.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the smoke barrier doors had an excessive gaps, that would not resist the passage of smoke.

Plan of Correction - To be completed: 04/15/2024

0374E: Based on observation, it was determined the facility failed to maintain smoke barrier doors in 3 instances.
1. The smoke barrier door gaps were repaired to the 3 main solarium, the 2 main solarium, and the 3 main and north side to ensure a proper seal.
2. The Maintenance Director audited the doors that were inspected and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on the regulation of having the smoke door full seal and gap requirements.
4. Those locations will be audited 2 times a week for 3 weeks; then 2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, in one of four smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101 (2012).

Findings include:

1. Observation on March 6, 2024, at 8:48 a.m., revealed an open electrical junction box above the in room P-100 of Grove two.

Interview with the Facility Administrator and staff on March 6, 2024, at 2:00 p.m., confirmed the open electrical junction box.

Plan of Correction - To be completed: 04/15/2024

0911D: Building failed to maintain electrical wiring in one instance in one of four smoke compartments.
1. The open electrical junction box in room 100 on Grove 1 was properly covered.
2. The Maintenance Director audited the junction box and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on the regulation and policy for properly covering junction boxes.
4. That location will be audited 2 times a week for 3 weeks; then 2 times a month for 2 months, reporting all findings to Quality Assurance.

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 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on March 4, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The annual 90 minute load bank;
b) The annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.

Plan of Correction - To be completed: 04/15/2024

0918F: Based on observation, it was determined the facility failed to maintain the emergency generator 2 two instances.
1. The annual 90-minute load bank test was completed. The annual fuel test quality was completed.
2. The Maintenance Director audited for completion of annual 90-minute load bank test and annual fuel test quality.
3. The Maintenance Director will be re-in-serviced by the Licensed Administrator on the requirement and facility policy to ensure an annual 90-minute load bank test and annual fuel test quality are completed.
4. The Maintenance Director or designee will review annually to ensure completion of the plan of correction and report findings to the QA to ensure regulatory compliance.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 26 smoke compartments.

Findings include:

1. Observation on March 6, 2024, at 9:47 a.m., revealed a refrigerator was plugged into a power strip in the resident account office.

Interview with the Facility Administrator and Director of Maintenance on March 6, 2024, at 2:00 p.m., confirmed the listed electrical wiring systems and equipment deficiency.

Plan of Correction - To be completed: 04/15/2024

0920D: Based on observation, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance.
1. The power strip in the Business Office was removed.
2. The Maintenance Director audited the Business Office area and found no deficiencies.
3. The Business Office will be re-in-serviced by the Maintenance Director on not using power strips.
4. The location will be audited 2 times a week for 3 weeks; than2 times a month for 2 months, reporting all findings to Quality Assurance.

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

Facility ID# 020802
Component 02
Annex Building

Based on a Medicare/Medicaid Recertification Survey completed on March 4-6, 2024, it was determined that Brighton Rehabilitation and Wellness 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 three-story, Type II (000), unprotected noncombustible building, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of six smoke compartments.

Findings include:

1. Observation on March 4, 2024, revealed the following deficiencies that would prevent proper operation of the automatic sprinkler system:

a) 9:50 a.m., there was a missing ceiling tile in the custodial closet on one west;
b) 9:55 a.m., there was a gap greater than 1/8" in the ceiling tile across from the mechanical room on one west.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

\\

Plan of Correction - To be completed: 04/15/2024

0353E: BUILDING 2 Based on observation, it was determined the facility failed to maintain the automatic sprinkler system in 2 instances.
1. The ceiling tile on 1 west in the custodial closet was replaced. 3M Fire Barrier Sealant CP 25WB + 4 hour rated sealant was used to patch holes by 1 west mechanical room.
2. The Maintenance Director audited those 2 locations to ensure all corrections were made, satisfying the requirements for the sprinkler system was met.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on inspecting, identifying and replacing bad ceiling tiles and holes.
4. Those 2 locations will be audited 2 times a week for 3 weeks; than2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting three of six smoke compartments.

Findings include:

1. Observation on March 6, 2024, revealed the following smoke barrier door deficiencies:

a) 9:29 a.m., the smoke barrier doors equipped with a self closing device in 2 West, near the custodial closet, failed to latch when tested;
b) 10:04 a.m., the smoke barrier doors equipped with a self closing device in 2 West, near the kitchen, failed to latch when tested;.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the smoke barrier doors failed to latch when tested.

Plan of Correction - To be completed: 04/15/2024

0374E: BUILDING 2 Based on observation, it was determined the facility failed to maintain smoke barrier doors in 2 instances.
1. The 2 doors by 2 west near housekeeping closet and kitchen were repaired to latch.
2. The Maintenance Director audited the doors were inspected and found no deficiencies.
3. The Maintenance staff will be re-in-serviced by the Maintenance Director on the regulation and policy for ensuring the smoke doors close and latch.
4. Those locations will be audited 2 times a week for 3 weeks; than2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Electrical Systems - Other:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, in one of four smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101 (2012).

Findings include:

1. Observation on March 4, 2024, at 9:48 a.m., revealed an open electrical junction box above the corridor ceiling, near the One West smoke barrier doors.

Interview with the Facility Administrator and staff on March 6, 2024, at 2:00 p.m., confirmed the open electrical junction box.

Plan of Correction - To be completed: 04/15/2024

0911E: BUILDING 2 Building failed to maintain electrical wiring in one instance in one of four smoke compartments.
1. The junction box above the corridor ceiling near the 1 West smoke barrier door was properly closed.
2. The Maintenance Director audited the junction box and found no deficiencies.
3. The Maintenance will be re-in-serviced by the Maintenance Director to ensure junction boxes are properly closed.
4. The location will be audited 2 times a week for 3 weeks; then 2 times a month for 2 months, reporting all findings to Quality Assurance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on March 4, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The annual 90 minute load bank;
b) The annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.

Plan of Correction - To be completed: 04/15/2024

0918F: BUILDING 2 Based on observation, it was determined the facility failed to maintain the emergency generator 2 two instances.
1. The annual 90-minute load bank test was completed. The annual fuel test quality was completed.
2. The Maintenance Director audited for completion of annual 90-minute load bank test and annual fuel test quality.
3. The Maintenance Director will be re-in-serviced by the Licensed Administrator on the requirement and facility policy to ensure an annual 90-minute load bank test and annual fuel test quality are completed.
4. The Maintenance Director or designee will review annually to ensure completion of the plan of correction and report findings to the QA to ensure regulatory compliance.

Initial comments:Name: LTSR ADDITION - Component: 03 - Tag: 0000

Facility ID# 020802
Component 03
LTSR Building

Based on a Medicare/Medicaid Recertification Survey completed on March 4-6, 2024, it was determined that Brighton Rehabilitation and Wellness 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 II (000), unprotected noncombustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: LTSR ADDITION - Component: 03 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on March 4, 2024, at 8:40 a.m., revealed the facility failed to perform the following required emergency generator testing:

a) The annual 90 minute load bank;
b) The annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director on March 6, 2024, at 2:00 p.m., confirmed the missing generator testing documentation.

Plan of Correction - To be completed: 04/15/2024

0918F: LTSR Based on observation, it was determined the facility failed to maintain the emergency generator 2 two instances.
1. The annual 90-minute load bank test was completed. The annual fuel test quality was completed.
2. The Maintenance Director audited for completion of annual 90-minute load bank test and annual fuel test quality.
3. The Maintenance Director will be re-in-serviced by the Licensed Administrator on the requirement and facility policy to ensure an annual 90-minute load bank test and annual fuel test quality are completed.
4. The Maintenance Director or designee will review annually to ensure completion of the plan of correction and report findings to the QA to ensure regulatory compliance.

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