Pennsylvania Department of Health
LIBERTY CENTER FOR REHABILITATION AND NURSING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LIBERTY CENTER FOR REHABILITATION AND NURSING - 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 August 13, 2024, it was determined that Liberty Center for Rehabilitation and Nursing had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with Patients:

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

§483.73(c)(8); §483.475(c)(8)

*[For LTC Facilities at §483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at §483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, it was determined the facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan, that the facility has determined appropriate, with residents and their families or representatives, affecting the entire facility.

Findings include:

Document review and interview on August 13, 2024, at 8:15 a.m., revealed the emergency communications plan did not include a method of sharing information from the emergency plan with residents and their families or representatives, affecting the entire facility.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. The facility immediately placed signs in the building and on the website, informing families and representatives that the facility's emergency plan is available in the lobby for anyone to review.
2. The whole facility could have been affected by this alleged deficient practice.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations, with an emphasis on the importance of informing families and representatives about the location of the facility's emergency plan.
4. The availability and location of the emergency plan will be audited once a month for the next three months to ensure it remains easily accessible to family members. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure continued compliance.

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

Facility ID# 193802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 13, 2024, it was determined that Liberty Center For Rehabilitation and Nursing 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, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 test/clean carbon monoxide alarms in accordance with 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

Document review on August 13, 2024, at 8:15 a.m., revealed the facility failed to provide documentation of a policy for testing and cleaning carbon monoxide detectors in accordance with manufacturer's specifications.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. The facility immediately cleaned all carbon monoxide alarms to ensure they are free of dust and debris.
2. All carbon monoxide alarms will be audited to ensure they are in proper working order following the cleaning.
3. The Nursing Home Administrator (NHA) and maintenance Director was re-educated on the relevant regulations, with a specific focus on the importance of regular cleaning and maintenance of carbon monoxide alarms.
4. Carbon monoxide alarm cleaning will be audited once a month for the next three months to ensure they are properly cleaned .
The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure continued 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 obstructions, affecting the entire facility.

Findings include:

Document review on August 13, 2024, at 8:15 a.m., revealed the facility could not provide a snow removal policy.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. The facility immediately located the snow removal policy.
2. Snow removal policy was reviewed.
3. The Nursing Home Administrator (NHA) and maintenance Director was re-educated on the importance on having documents easily accessible .
4. Snow policy will be audited once a month for the next three months to ensure they are easily accessible . The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

NFPA 101 STANDARD Egress Doors:

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.

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 one of three levels in the facility.

Findings include:

Observation on August 13, 2024, at 10:36 a.m., revealed, on the first floor, the delayed egress door from Physical Therapy failed to alarm when pushed.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the door failed to alarm.

Plan of Correction - To be completed: 10/01/2024

1. The delayed egress door from Physical Therapy was immediately repaired.
2. All delayed egress doors will be audited to ensure they properly alarm when pushed.
3. The Nursing Home Administrator (NHA) and maintenance Director was re-educated on the relevant regulations, with an emphasis on ensuring that delayed egress doors alarm appropriately when pushed open.
4. delayed egress doors will be audited once a month for the next three months to ensure that they are in proper working order. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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 inspect exit signage, affecting the entire facility.

Findings include:

Document review on August 13, 2024, at 8:15 a.m., revealed the facility could only provide documentation of monthly exit sign inspections for June and July of 2024.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. Documentation of the monthly exit sign inspections was immediately located.
2. An audit of exit signs inspections will be conducted to ensure they are easily accessible.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on having documents easily accessible.
4. monthly exit sign inspections will be audited once a month for the next three months to ensure easily accessible . The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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 storage areas, affecting one of three levels in the facility.

Findings include:

Observation on August 13, 2024, at 10:44 a.m., revealed, on the first floor, the Storage Room next to the Executive Director office lacked a self closer.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of self closer.

Plan of Correction - To be completed: 10/01/2024

1. The boxes in the room next to the Executive Director's office were cleared out, and the room has been restored to its intended use as an office.
2. All storage rooms will be audited to ensure they are equipped with self-closing doors.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations , with an emphasis on storage rooms self-closers.
4. Storage rooms will be audited once a month for the next three months to ensure compliance with the self-closer requirement. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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 and interview, it was determined the facility failed to maintain and inspect kitchen hood systems, affecting the entire facility.

Findings include:

Document review on August 13, 2024, at 8:15 a.m., revealed the facility could not provide documentation of a semi-annual kitchen exhaust hood cleaning within 6 months prior to 5/16/2024.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. Documentation of the semi-annual kitchen exhaust hood cleaning was immediately located.
2. The whole facility could have been affected by this alleged deficient practice.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the importance of keeping essential documents easily accessible.
4. Hood inspection documentation will be audited once a month for the next three months to ensure it remains easily accessible. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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 August 13, 2024, at 8:15 a.m., revealed the facility could not provide documentation of the following:

a. Multiple detectors on the 5/1/2024 inspection report were noted as deficient. No evidence of their repair/replacement was provided;
b. 2 year smoke detector sensitivity.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. The facility's fire vendor was immediately called to repair the fire detectors noted as deficient and Tilley fire is scheduled to complete a two-year smoke detector sensitivity test on 9/20.
2. Fire detectors will be audited to ensure they are in proper working order.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations with an emphasis on smoke detector maintenance.
4. Smoke detectors will be audited once a month for the next three months to ensure they are in proper working order. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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 and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

1. Document review on August 13, 2024, at 8:15 a.m., revealed the facility could not provide documentation of a third quarter, 2023 sprinkler inspection.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

2. Observation on August 13, 2024, at 10:50 a.m., revealed, in the Basement, the gauges on the sprinkler riser were more than 5 years old.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the gauges were out of date.

Plan of Correction - To be completed: 10/01/2024

1. Documentation of the third quarter 2023 sprinkler inspection was located, and the repair of the gauges on the sprinkler riser was scheduled.
2. Sprinkler inspections will be audited to ensure compliance.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations, with an emphasis on having documents easily accessible.
4. Sprinkler inspections will be audited once a month for the next three months to ensure accessibility of documentation. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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, affecting one of three levels in the facility.

Findings include:

Observation on August 13, 2024, at 10:41 a.m., revealed, on the first floor, one leaf of the smoke barrier doors did not have a self closer.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of self closer.

Plan of Correction - To be completed: 10/01/2024

1. The self-closer on the first-floor smoke barrier door was scheduled for repair.
2. All smoke barrier doors will be audited to ensure they have functioning self-closers.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations, with a focus on ensuring that smoke barrier doors have self-closers.
4. Smoke barrier doors will be audited once a month for the next three months to ensure they are in compliance. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing 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 the entire facility.

Findings include:

Observation on August 13, 2024, between 10:42 a.m. and 10:49 a.m., revealed storage within three feet of the electrical panels in the following 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. 10:42 a.m., on the first floor, Nurses Station;
b. 10:49 a.m., in the Basement, Boiler Room.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the blocked electrical panels.

Plan of Correction - To be completed: 10/01/2024

1. Storage in front of the electrical panels was immediately removed.
2. Electrical panels will be audited to ensure nothing is blocking them.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations, with an emphasis on keeping electrical panels clear of obstructions.
4. Electrical panels will be audited once a month for the next three months to ensure they remain free of storage. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing 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 did not maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on August 13, 2024, at 8:15 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Weekly battery voltage;
b. Annual 90-minute load bank;
c. Generator's preventative maintenance indicating no evidence of wet stacking.

Exit interview with the Regional Director of Nursing and the Maintenance Director on August 13, 2024, at 11:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/01/2024

1. The weekly battery voltage test was completed, and the annual 90-minute load bank test documentation was located. Generator preventative maintenance records showing no evidence of wet stacking were also located.
2. It was acknowledged that the entire facility could have been affected by this alleged deficient practice.
3. The Nursing Home Administrator (NHA) and Maintenance Director was re-educated on the relevant regulations, with an emphasis on maintaining and accessing critical documents.
4. Generator maintenance records will be audited once a month for the next three months to ensure they are easily accessible. The results of these audits will be reported to the Quality Assurance/Performance Improvement (QAPI) Committee on a monthly basis until substantial compliance is achieved. The frequency of these audits will be adjusted based on the findings to ensure ongoing compliance.

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