Pennsylvania Department of Health
HUNTINGDON SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 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.


HUNTINGDON SKILLED NURSING AND REHABILITATION 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 21, 2024, it was determined that Huntingdon Skilled Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004
Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.
Findings include:
1. Document review on March 21, 2024, at 8:45 am, revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.
Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 am, confirmed the documentation was not available.

Plan of Correction - To be completed: 05/20/2024

The maintenance director or designee will complete the Emergency Preparedness Plan for 2024. The NHA and Maintenance Director will be re-educated on the completion of the emergency preparedness plan annually. NHA or designee will complete a quarterly audit to ensure the plan is updated. The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

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

Facility ID# 053802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 21, 2024, it was determined that Huntingdon Skilled Nursing And Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 two-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to update facility policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act; failed to provide accurate, portable floor plans as required, affecting the entire facility.

Findings include:

1. Document review on November 7, 2017 at 8:15 a.m., revealed the facility failed to provide a carbon monoxide alarm evacuation plan and associated staff in-service to the plan.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the facility did not adhere to the Care Facility Carbon Monoxide Alarms Standards Act.

2. Document review on March 21, 2024, at 8:45 am, revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed accurate floor plans were not available.

Plan of Correction - To be completed: 05/20/2024

NHA and the maintenance director were re-educated on the carbon monoxide policy. Staff will be inserviced on the policy.
Floor plans have been updated to standards to have on file and immediately available. NHA or the designee will re-educate the maintenance director to ensure floor plans have been updated. NHA or the designee will complete a quarterly audit to ensure the floor plan and carbon monoxide policy are updated and/or reviewed. The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

NFPA 101 STANDARD Means of Egress - General:

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.

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 document review and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not provide documentation of a snow removal policy.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

NHA and the maintenance director were re-educated on the snow removal policy. The policy was provided and updated in the life safety binder. Quarterly audits will be completed by NHA or designee x 2, the results will be reviewed at the QAPI meeting x2 to ensure compliance.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain delayed egress doors, affecting the entire facility.

Findings include:

Observations on March 21, 2024, between 10:53 a.m. and 11:31 a.m., revealed the following deficiencies:

a. 10:53 a.m., on the first floor, delayed egress door by the Kitchen failed to open after 15 seconds;
b. 11:29 a.m., on the ground floor, delayed egress door by resident room 43 lacked signage stating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS";
c. 11:31 a.m., on the ground floor, delayed egress door by resident room 36 lacked signage stating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS".
Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 05/20/2024

Kitchen door will be repaired. Once repair is complete, weekly audits x3 months will be completed by the maintenance director or designee. Staff is educated on the door codes, residents may not have codes and due to it being a dementia unit, the signs not up are helping to reduce elopement and exit seeking. NHA or designee will complete random weekly audits x 3 months for knowledge of door codes. Audits will be completed and presented at the QAPI meeting x3 by the
Maintenance Director/designee.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of stairwell enclosures, affecting one of two levels in the facility.

Findings include:

Observation on March 21, 2024, at 11:31 a.m., revealed, on the ground floor, in the stairwell near resident room 36, storage under the stairs.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the improper storage.

Plan of Correction - To be completed: 05/20/2024

The Facility Maintenance Director was educated on the documentation requirements for inspection and cleaning of the kitchen hood/suppression system.
The Inspection company contracted to service the kitchen suppression system was contacted for copies of previous inspection documentation
to have on file and immediately available.
The Kitchen hood cleaning company contracted to clean the hood/ducts was contacted for copies of previous hood/duct cleaning documentation to have on file and immediately available.
Kitchen inspections and cleanings will be scheduled by the Maintenance Director and documentation of such will be reviewed in the next month's QAPI meeting in 2024 to ensure compliance.

NFPA 101 STANDARD Illumination of Means of Egress:

Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

Based on document review and interview, it was determined the facility failed to maintain and inspect battery back-up lighting, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not produce documentation of the following:

a. Monthly 30 second testing;
b. Annual 90 minute testing.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

Plan of Correction: The maintenance director or designee will complete monthly and annual testing of the backup lighting. NHA or the designee will re-educate the maintenance director on the completion of backup light testing. Quarterly audits will be completed by NHA or designee x 2. The results of the audit will be presented at the QAPI meeting x3 by the
Maintenance Director/designee.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

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

Based on document review and interview, it was determined the facility failed to maintain and inspect exit signage, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not produce documentation of monthly exit sign inspections.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

The maintenance director or designee will complete monthly and annual testing of the backup lighting. NHA or the designee will re-educate the maintenance director on the completion of backup light testing. Quarterly audits will be completed by NHA or designee x 2. The results of the audit will be presented at the QAPI meeting x3 by the
Maintenance Director/designee.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review, observation, and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting the entire facility.

Findings include:

1. Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not provide documentation of the following:

a. Semi-annual testing of the kitchen hood suppression system;
b. Semi-annual cleaning of the kitchen exhaust hood and duct.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

2. Observation on March 21, 2024, at 10:50 a.m., revealed, on the first floor, in the Kitchen, the kitchen hood suppression system lacked monthly visual inspections.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the missing monthly inspections.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiation devices, affecting one of two levels in the facility.

Findings include:

Observation on March 21, 2024, at 11:08 a.m., revealed, on the first floor, in the Nurses Station, the pull station was blocked by a trash receptacle.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the blocked pull station.

Plan of Correction - To be completed: 05/20/2024

Maintenance director removed the shred box from the pull station and educated staff to ensure it is not blocking the pull station. Weekly audits x 3 will be completed by the Maintenance Director or designee to ensure that the pull stations are not blocked. Audits will be completed and presented at the QAPI meeting x3 by the Maintenance Director/designee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not provide documentation of a semi-annual fire alarm inspection within 6 months of 8/7/2023.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

The Facility Maintenance Director was educated on the documentation requirements for the fire alarm system testing and maintenance. Fire alarm testing was completed.
Fire alarm testing and maintenance documentation will be reviewed
monthly in the 2024 QAPI meetings to ensure compliance.

NFPA 101 STANDARD Fire Alarm System - Out of Service:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0346

Based on document review and interview, it was determined the facility failed to maintain required policies for the fire alarm system, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility did not have a fire watch policy to implement in the event the required fire alarm system was out of service for more than four hours in a 24-hour period.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the missing policy.

Plan of Correction - To be completed: 05/20/2024

The fire watch policy was reviewed by NHA and Maintenance, we will be re-educated on the fire watch policy. Quarterly x 2 review of the policy will be completed by NHA and Maintenance. Audits will be completed and presented at the QAPI meeting by the Maintenance Director/designee.

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 document review, observation, and interview, it was determined the facility failed to maintain and inspect the sprinkler systems, affecting the entire facility.

Findings include:

1. Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Fourth quarter of 2023 sprinkler inspection;
b. Dry system full flow trip test (3 year);
c. Internal valve and pipe inspection (5 year).

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

2. Observation on March 21, 2024, at 11:16 a.m., revealed, on the ground floor, in the Laundry, excessive debris on the sprinklers behind the dryers.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the excessive debris on the sprinklers.

Plan of Correction - To be completed: 05/20/2024

The Facility Maintenance Director was educated on the documentation requirements for the maintenance and testing of the sprinkler system.
The contracted Sprinkler system contracted service company was contacted for new copies of the following inspections to have on file
and immediately available: Fourth quarter of 2023 sprinkler inspection; Dry system full flow trip test (3 year); Internal valve and pipe inspection (5 year). Area behind the dryers were cleaned of debris.
Sprinkler system maintenance and testing will be scheduled for calendar year 2024 by the Maintenance Director/designee. All sprinkler system documentation will be reviewed in the 2024 QAPI meetings to ensure compliance.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review, observation, and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings include:

1. Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not provide documentation of the following:

a. Annual maintenance;
b. Certification for the technician conducting the annual maintenance.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

2. Observations between 11:03 a.m. and 11:25 a.m., revealed the following:

a. 11:03 a.m., on the first floor, portable fire extinguisher in the Beauty Barber room lacked an annual inspection and monthly visual inspection since 12/2023;
b. 11:25 a.m., on the ground floor, portable fire extinguisher by resident room 11 was blocked by a bed.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 05/20/2024

Certification has been received for the tech who does the inspections and is on file in the life safety manual.
NHA or designee will re-educate the maintenance director on rounding to ensure tags or up to date for portable fire extinguishers. The maintenance Director or designee will complete weekly audits x 4 to confirm extinguishers are up-to-date.
The life safety manual will be reviewed weekly by the Maintenance Director. The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

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 the smoke resistance of corridor doors, affecting one of two levels in the facility.

Findings include:

Observations on March 21, 2024, between 11:05 a.m. and 11:07 a.m., revealed the following deficiencies:

a. 11:05 a.m., on the first floor, the Storage Room across from resident room 125, failed to latch;
b. 11:07 a.m., on the first floor, the Oxygen Storage Room, hole above the door hardware.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 05/20/2024

The doors will be repaired to ensure there are no holes in doors to maintain the smoke resistance of corridor doors.
Door closures will be reviewed weekly x 3 by the Maintenance Director during facility rounds. The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two levels in the facility.

Findings include:

Observations on March 21, 2024, between 10:54 a.m. and 11:10 a.m., revealed storage within three feet of the electrical panels in in the below locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

a. 10:54 a.m., on the first floor, Mechanical Room;
b. 11:10 a.m., on the first floor, Soiled Utility by the Nurses Station.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the improper storage in front of the electrical panels.

Plan of Correction - To be completed: 05/20/2024

Maintenance Director removed the equipment from the panels to ensure there is nothing within 3 feet of the panels. All staff was re-educated to ensure nothing is blocking the electrical panels. Weekly audits x 3 will be conducted by maintenance or designee to ensure compliance. The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to ensure that facility's fire dampers were exercised at 4 year intervals, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility could not provide documentation that the facility's fire dampers had been exercised within the previous 48 months.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

The Facility Maintenance Director was educated on the documentation requirements for fire/smoke dampers.
The contracted fire suppression service company was contacted for a copy
of the four-year fire/smoke dampers inspections to have on file and
immediately available. Evidence of fire/smoke damper inspection will be
reviewed by the Maintenance Director at the QAPI meeting.

NFPA 101 STANDARD Evacuation and Relocation Plan:

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0711

Based on documentation review and interview, it was determined the facility failed to provide a fire alarm evacuation plan, affecting the entire facility.

Findings include:

Document review performed on March 21, 2024, at 8:45 a.m., revealed the facility could not provide a fire alarm evacuation plan.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the facility could not provide a fire alarm evacuation plan.

Plan of Correction - To be completed: 05/20/2024

NHA and the maintenance director were re-educated on the fire evacuation plan. The plan is up-to-date and will be audited quarterly x 3 by the NHA or designee. The fire evacuation plan will be reviewed by the Maintenance Director at the QAPI meeting.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on documentation review and interview, it was determined the facility failed to provide a smoking/non-smoking policy, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed the facility failed to provide documentation of a smoking/non-smoking policy.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

NHA and maintenance were re-educated on the non-smoking policy. The policy is updated and in the life safety binder. NHA or designee will review quarterly x 3 to ensure it is up-to-date. The smoking policy will be reviewed by the Maintenance Director at the QAPI meeting.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to ensure that rated fire door assemblies were inspected and tested annually, affecting the entire facility.

Findings include:

Document review on March 21, 2024 at 8:45 a.m., revealed the facility could not provide documentation that rated fire door assemblies were inspected and tested within the previous 12 months.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the facility could not provide documentation that fire door assemblies were inspected and tested within the previous 12 months.

Plan of Correction - To be completed: 05/20/2024

The Facility Maintenance Director was educated on the annual documentation requirements for fire doors. Evidence of annual fire door inspections will be located, or completed if not already done, and
presented at the QAPI meeting x 3 by the Maintenance Director/designee.

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 01 - Component: 01 - Tag: 0912

Based on documentation review and interview, it was determined the facility failed to ensure that electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility.

Findings include:

Document review on March 21, 2024, at 8:45 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the facility could not provide documentation that the receptacles were tested.

Plan of Correction - To be completed: 05/20/2024

The maintenance director or designee will complete monthly and annual testing of electrical receptacles. NHA or designee will re-educate the maintenance director on the completion of electrical receptacles testing. Monthly audits will be completed by NHA or designee x 3. The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

1. Document review on March 24, 2024, at 8:45 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. Weekly visual inspections prior to 10/2023;
b. Weekly battery voltage inspection prior to 10/2023;
c. Monthly battery conductance testing;
d. Annual 90 minute load bank test;
e. Preventative Maintenance report indicating no evidence of wet stacking;
f. 3 year, 4 hour load test;
g. Annual fuel quality test.

Exit interview with the the Administrator and Maintenance Director, on March 21, 2024 at 11:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/20/2024

The boxes, trash carts, chairs, etc. were immediately removed from the upper-level transformer room and relocated to a safe location. Weekly audits x 4 will be completed by maintenance or designee to ensure the upper-level transformer room is clear of storage and combustible items. The maintenance director/designee will complete a monthly audit to ensure the upper-level transformer room is free of combustible items. Audit results will be presented at the QAPI meeting x3.
The facility Maintenance Director was educated on the requirements for testing of the emergency generator components. The Maintenance Director will complete ongoing documentation of the following emergency generator maintenance items: weekly visual inspection, weekly voltage inspection, monthly battery conductance testing, monthly load test, monthly transfer switch operation, annual fuel quality test report
provided by the generator service vendor
Emergency Generator component testing results will be reviewed
monthly at the QAPI meeting x3 to ensure compliance.

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