Nursing Investigation Results -

Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RIDGEVIEW HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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.
RIDGEVIEW HEALTHCARE 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 February 25, 2019, it was determined that Ridgeview Healthcare 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:


483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and Patients: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.
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015

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

Findings include:

1. Document review on February 25, 2019, at 1:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that included:
a. Subsistence needs for staff and patients (specifically waste disposal).
b. Sustainable power during an emergency (specifically diesel fuel supply).
c. Alternate power sources.
d. Maintenance of building temperatures.
e. Fire detection, extinguishing, and alarm systems.

If the above is not able to be maintained throughout an emergency, an evacuation would have to occur at that time.

Interview with the maintenance director and director of nursing on February 25, 2019, at 1:00 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.








 Plan of Correction - To be completed: 04/09/2019

The facility's Emergency Preparedness Plan (EPP) will be updated by the facility's Administrator to include emergency emergent agreements for sanitation disposal, back up generator, and diesel fuel for generator. These contracts will be included as part of the plan.

The EPP will be reviewed and updated as necessary at least annually.

Agreements will be reported to the Quality Assurance and Performance Improvement (QAPI) committee.

483.73(c)(1) REQUIREMENT Names and Contact Information: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.
[(c) The [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:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

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

Findings include:

1. Document review on February 25, 2019, at 1:30 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes a communication plan that complies with federal, state and local laws (including names and contact information for staff, resident's physicians, other facilities, volunteers, and federal, state, tribal, and local emergency staff).

Interview with the maintenance director and director of nursing on February 25, 2019, at 1:30 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.






 Plan of Correction - To be completed: 04/09/2019

The facility's EPP will be updated by the Administrator and include a communication plan that complies with federal, state and local laws which includes name and contact information for staff, resident's physicians, other facilities, volunteers, and federal, state and local agencies.

The EPP will be reviewed and updated as necessary at least annually.

Contact lists will be presented to the QAPI committee.


483.73(d) REQUIREMENT EP Training and Testing:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

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

*[For ESRD Facilities at 494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be reviewed and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0036

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

Findings include:

1. Document review on February 25, 2019, at 1:45 p.m., revealed the facility performed an emergency management training and testing for all staff that was generic-type, and not specific to the facility.

Interview with the maintenance director and director of nursing on February 25, 2019, at 1:45 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.






 Plan of Correction - To be completed: 04/09/2019

The EPP will include an annual mandatory training for all employees and volunteers. Additionally, all new employees and volunteers with complete this mandatory training within 2 weeks from their start date. This training will be supported by live drills, table top and county first responder's evacuation drills.

The EPP training program will be reviewed and updated as necessary at least annually.

EPP training program and results will be viewed the QAPI committee.


483.73(d)(1) REQUIREMENT EP Training Program: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.
(1) Training program. The [facility, except CAHs, ASCs, PACE organizations, PRTFs, Hospices, and dialysis facilities] must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For Hospitals at 482.15(d) and RHCs/FQHCs at 491.12:] (1) Training program. The [Hospital or RHC/FQHC] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For Hospices at 418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least annually.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.

*[For PRTFs at 441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.

*[For PACE at 460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.

*[For CORFs at 485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.

*[For CAHs at 485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CMHCs at 485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least annually.

Observations:
Name: - Component: -- - Tag: 0037

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

Findings include:

1. Document review on February 25, 2019, at 2:00 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes an initial training on emergency management for individuals providing services (including volunteers).

Interview with the maintenance director and director of nursing on February 25, 2019, at 2:00 p.m., confirmed the Emergency Preparedness Plan did not include the above elements.





 Plan of Correction - To be completed: 04/09/2019

The EPP will include an annual mandatory training for all employees and volunteers. Additionally, all new employees and volunteers with complete this mandatory training within 2 weeks from their start date. This training will be supported by live drills, table top and county first responder's evacuation drills.

The EPP training program will be reviewed and updated as necessary at least annually.

EPP training program and results will be viewed the QAPI committee.


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


Facility ID # 015002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 25, 2019, it was determined that Ridgeview Healthcare and Rehabilitation Center, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected, wood frame building, with a partial 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 interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient, in one of one facility.

Findings include:

1. Phone call interview on February 26, 2019, at 11:00 a.m., with the director of maintenance and director of nursing (concerning on-site survey on February 25, 2019), revealed plans were submitted to state plan review for the following projects, but the facility did not request an occupancy approval from the Division of Life Safety for the following projects:
a. Alterations to upgrade the existing Ansul system in the kitchen exhaust hood (H-17-0084.
b. Alterations to replace the existing fire alarm system throughout the building (H-16-0807).

Interview with the maintenance director and director of nursing on February 26, 2019 (phone call), at 11:00 a.m., revealed occupancies from the Division of Life Safety were not granted for the above state approved drawings.





 Plan of Correction - To be completed: 04/09/2019

The facility's engineer submitted final occupancy requests for the Fire Alarm System and Kitchen Ansul System upgrade on 2/26/19. Facility is awaiting Life Safety's final notice and completion of the final occupancy inspections.

With each building project, facility engineer will ensure all documentation and requests are completed with projects requiring Life Safety's approval and inspections.

Results of final occupancy inspection will be presented to the QAPI committee when completed.

NFPA 101 STANDARD Illumination of Means of Egress: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.
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, the facility failed to maintain illumination of exits in all areas of the building.

Findings include:

1. Document review on February 25, 2019, at 10:45 a.m., revealed the facility lacked consistent documentation, to indicate a monthly, visual inspection of all exit signs was performed, within the last year.

Interview with maintenance staff #1 on February 25, 2019, at 10:45 a.m., confirmed the above exit sign visual documentation was not documented consistently on a monthly basis.









 Plan of Correction - To be completed: 04/09/2019

The facility's maintenance director and/or designee have been educated on the need to visually inspect all of the facility's exit signs on a monthly basis. The monthly inspection results of will be captured and documented in TELs and/or log.

The Maintenance Director and/or designee will be responsible to perform, complete, and record monthly exit sign inspection.

Nursing Home Administrator (NHA) will monitor to ensure inspection and records occur and are maintained.

Results of the inspection will be presented to the QAPI committee.

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

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous areas on one of two building levels.

Findings include:

1. Observation on February 25, 2019, at 12:55 p.m., revealed the basement, soiled linen room door, had the arm of the self-closure removed.

Interview with maintenance staff #1 on February 25, 2019, at 12:55 p.m., revealed the self-closure on the above soiled linen room door, did not function properly.





 Plan of Correction - To be completed: 04/09/2019

The facility will install the proper self closure mechanism on the soiled utility door in the basement to meet the hazardous area-enclosure requirements. Additionally, all other doors have been evaluated and those requiring self closures have been addressed.

The Maintenance Director and NHA will be responsible to ensure the self closure devices are placed on soiled utility door.

Completion of the self closure audit and placement will be reported to the QAPI committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Fire 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, the facility failed to maintain the fire alarm system for one of one fire alarm system.

Findings include:

1. Document review on February 25, 2019, at 9:40 a.m., revealed the facility lacked documentation, to indicate a semi-annual, visual inspection, of all fire alarm devices was performed six months prior to December 20, 2018.

Interview with the maintenance director on February 25, 2019, at 9:40 a.m., confirmed the above fire alarm visual documentation was not on-site during the time of the survey.




 Plan of Correction - To be completed: 04/09/2019

The facility's Maintenance Director and Designee have been educated on the need and requirement to visually inspect all of the fire alarms systems semi annually. Additionally, supporting documentation and recordings of the results must be completed and available in TELs and/or log. If this work is done in conjunction with fire system contractor, their inspection records must be included in TELs and/or Log.

Maintenance director and/or designee will be responsible for completing and maintaining written records of the required testing.

NHA or designee will monitor to assure that testing and recording is occurring and maintained.

Results of the testing will be reported in the QAPI committee.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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, the facility failed to maintain the fire sprinkler system for one of one fire sprinkler system.

Findings include:

1. Document review on February 25, 2019, at 9:45 a.m., revealed the facility lacked documentation to indicate that the fire sprinkler second and third quarter 2018 flow tests were performed.

Interview with the maintenance director on February 25, 2019, at 9:45 a.m., confirmed the above fire sprinkler documentation was not available at the time of the survey.

2. Document review on February 25, 2019, at 9:55 a.m., revealed the most recent quarterly flow test of the sprinkler system (January 16, 2019), indicated the following deficiencies:
a. Some pendant heads have physical damage and should be replaced.
b. Drum drips shall be installed where drain valves are currently located to provide proper maintenance.
c. Pendant installed as an upright in compressor room.

Interview with the maintenance director on February 25, 2019, at 9:55 a.m., confirmed the above fire sprinkler deficiencies were listed on the most recent quarterly flow test report.

3. Document review on February 25, 2019, at 11:00 a.m., revealed the facility lacked consistent documentation to indicate a monthly no-flow churn test was performed on the fire sprinkler pump, within the last year.

Interview with maintenance staff #1 on February 25, 2019, at 11:00 a.m., confirmed the above fire pump testing was not documented consistently on a monthly basis.

4. Observation on February 25, 2019, at 10:10 a.m., revealed the restroom in resident room #1, had an upright-type sprinkler head installed in the pendant position.

Interview with maintenance staff #1 on February 25, 2019, at 10:10 a.m., confirmed the above fire sprinkler head is not in the correct position.














 Plan of Correction - To be completed: 04/09/2019

The Maintenance Director and/or designee have been educated that:
* Quarterly flow tests of sprinkler system must be completed and written records or results completed in TELs and/or log.
* Monthly no-flow churn tests must be completed and written records or results completed in TELs and/or log.
Maintenance of replacing damaged pendant heads, upright pendant heads, and placement of drum drips will be completed.

Maintenance Director will be responsible for maintaining written records (including contractor's inspection and reports).

NHA or designee will monitor to assure that testing and maintenance is completed and that records are complete.

Results of the testing and maintenance will be reported the QAPI committee.


NFPA 101 STANDARD Smoking Regulations: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.
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 observation and interview, the facility failed to maintain smoking regulations at one of two designated smoking locations.

Findings include:

1. Observation on February 25, 2019, at 10:45 a.m., revealed the designated smoking area, outside of kitchen/dining area, had a cigarette butt container that was not self-closing.

Interview with maintenance staff #1 on February 25, 2019, at 10:45 a.m. revealed the above designated smoking area butt container was not self-closing.





 Plan of Correction - To be completed: 04/09/2019

The facility will replace the deficient self closing butt container.

The Maintenance Director will visually assess the self closing butt container each time that it is emptied.

Replacement of self closing butt container will be presented to QAPI committee.


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

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

Findings include:

1. Document review on February 25, 2019, at 10:15 a.m., revealed the following emergency generator documentation was not on-site during the time of the survey:
a. Weekly visual inspection performed on the emergency generator (including battery voltage/specific gravity) between April 23, 2018 and May 15, 2018.
b. Monthly full load test performed on the emergency generator for the month of January 2019.

Interview with maintenance staff #1 on February 25, 2019, at 10:15 a.m., confirmed the above emergency generator visual and testing documentation was not on-site during the time of the survey.





 Plan of Correction - To be completed: 04/09/2019

The Maintenance Director and/or designee have been educated that:
* Weekly visual inspection must occur and results documented in TELs and/or log
* Monthly full load testing must occur and results documented in TELs and/or log

The Maintenance Director will be responsible to performing and maintaining written records of these inspection and testing.

NHA or designee will monitor to assure that inspection and testing is being completed.

The results of these inspections will be reported to the QAPI committee.


NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to maintain oxygen cylinder storage in two of nine wings.

Findings include:

1. Observation on February 25, 2019, between 10:20 a.m. and 11:30 a.m., revealed the following oxygen cylinder storage deficiencies:
a. (10:20 a.m.) West corridor, main oxygen storage room door (by lounge), lacked positive latching with the self-closure.
b. (11:30 a.m.) East corridor, main oxygen storage room, had one unsecured oxygen cylinder.

Interview with maintenance staff #1 on February 25, 2019, at 11:30 a.m., revealed the above oxygen cylinder storage deficiencies.









 Plan of Correction - To be completed: 04/09/2019

The facility will correct the deficient latching mechanism in the door on West oxygen room. Nursing staff will be educated to place oxygen cylinders in the secure racks found in oxygen rooms.
Maintenance Director and/or designee will be responsible to address and correct latching mechanism issues. Director of Nursing and/or designee will educate the nursing staff and keep written attendance record of placing the oxygen tanks in the secure racks.
NHA will monitor that repair, training and attendance record are completed and maintained.
Results of repair and training will be reported to the QAPI committee.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port