Nursing Investigation Results -

Pennsylvania Department of Health
BELVEDERE CENTER, GENESIS HEALTHCARE, THE
Building Inspection Results

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BELVEDERE CENTER, GENESIS HEALTHCARE, THE
Inspection Results For:

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BELVEDERE CENTER, GENESIS HEALTHCARE, THE - 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 January 8, 2019, The Belvedere Center, Genesis Healthcare it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


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

Facility ID# 024202
Component 01
Main Mansion Building

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2019, it was determined that The Belvedere Center, Genesis Healthcare - Main Mansion Building 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 two-story, Type V (000), unprotected wood frame construction, with a partial basement, basement-level crawl space, and unused attic spaces, which is fully sprinklered.











 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to meet the minimum requirements for this construction type, affecting the entire building component.

Findings include:

1. Observation and documentation reviewed on January 8, 2019, between 8:30 a.m. and 2:30 p.m., revealed this building component has been classified as a two story, type V (000), unprotected wood frame construction. The building height exceeds the maximum allowance by one story.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed the building exceeded the maximum allowable story height.

















 Plan of Correction - To be completed: 02/28/2019

Facility request to utilize DOH to perform the 2019 FSES.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0225

Based on observation, document review and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting 2 of six smoke compartments.

Findings Include:

1. Observation and documentation reviewed on January 8, 2019, between 8:30 a.m. and 2:30 p.m., revealed wired glass vision panels were secured within non-rated aluminum frames within the main stairwell's enclosure wall.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed vertical openings lacked the required fire resistance rating.














 Plan of Correction - To be completed: 02/28/2019

Facility request to utilize DOH to perform the 2019 FSES.
NFPA 101 STANDARD Aisle, Corridor, or Ramp Width: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.
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0232

Based on observation, document review and interview, it was determined the facility failed to maintain minimum corridor widths, affecting 1 on four smoke zones within this component.

Findings include:

1. Observation and documentation reviewed on January 8, 2019, between 8:30 a.m. and 2:30 p.m., revealed the width of the second floor exit access corridor, adjacent to the interior exit stairway, was less than the required four feet.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed the corridor width was not maintained.













 Plan of Correction - To be completed: 02/28/2019

Facility request to utilize DOH to perform the 2019 FSES.
NFPA 101 STANDARD Number of Exits - Corridors: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.
Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4




Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0252

Based on observation, document review and interview, it was determined the facility failed to provide the minimum number of approved exits, affecting 2 of six smoke zones within this component.

Findings include:

1. Observation and documentation reviewed on January 8, 2019, between 8:30 a.m. and 2:30 p.m., revealed the basement and second floor levels lacked two acceptable exits, each remote from the other.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed the building lacked required exiting.










 Plan of Correction - To be completed: 02/28/2019

Facility request to utilize DOH to perform the 2019 FSES.
NFPA 101 STANDARD Corridor - 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.
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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with positive self-latching and smoke tight resistance along the means of egress, affecting 2 of five smoke compartments.

Findings Include:

1. Observation on January 8, 2019, at 1:45 pm, revealed resident room 302 corridor door rubbed against the carpet and would not latch when closed.

Exit Interview with Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 3:00 pm, confirmed the door failed to positively latch.


2. Observation made on January 8, 2019, at 1:56 p.m., revealed the corridor door knob to room 211 was loose it its housing, 1st floor south Mansion.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed the corridor door knob was not completely secured.








 Plan of Correction - To be completed: 02/28/2019

1.Repair door to positively latch in room 302.

1.Maintenance will complete a quarterly door audit to ensure all door latch positively within frame. Results of audit will be shown at the monthly QI meeting.

2.Maintenace will replace door handle for 211. Maintenance will complete a quarterly door audit to ensure all door latch positively within frame. Results of audit will be shown at the monthly QI meeting.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to complete required inspections of fire rated door assemblies, affecting the entire facility.

Findings include:

1. Documentation reviewed on January 8, 2019, between 8:30 a.m. and 12:00 p.m., revealed the annual fire door inspection report dated September 27, 2017 indicated door failures. Verification door adjustments were completed was not available at the time of inspection.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed compliance of fire door assemblies was not completed.















 Plan of Correction - To be completed: 03/08/2019

The results of the identified door failures from the Sept 27, 2017, will be provided showing all repair were completed.

Maintenance staffed in-serviced on proper required steps to complete and document all repairs done from the annual fire door inspection. Repairs on affected doors will be fixed within 45 days of Life Safety survey.
Results will be shared at monthly QI meeting.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Receptacles
Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0917

Based on document review and interview, it was determined the facility failed to maintain required testing of electrical receptacles, affecting all 150 resident bed locations.

Findings include:

1. Documentation reviewed on January 8, 2019, between 8:30 a.m. and 12:00 p.m., revealed electrical receptacles at patient resident bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and for hospital grade receptacles based on documented performance data or, minimally not exceeding 12 months. Receptacle testing should include the following:

a. resident 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 Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed testing of electrical receptacles was not provided.















 Plan of Correction - To be completed: 02/28/2019

1. Maintenance will complete an audit of all receptacles in all resident care areas to test, physical integrity, polarity of hot/neutral connections and retention fore of grounding blade.
Repair and or replace is they do not meet the requirements.

Maintenance staff will be in-service on policy and time frames required for the annual inspections. Results of the electrical receptacle inspection will be shared at monthly QI meeting.
Initial comments:Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0000


Facility ID# 024202
Component 02
South Wing

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2019, it was determined that The Belvedere Center, Genesis Healthcare - South Wing 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 483.70(a).

This is a two story, Type II (000), unprotected noncombustible construction, which is fully sprinklered.












 Plan of Correction:


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: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain required signage for delayed egress doors, affecting 1 of two stair enclosures within this building component.

Findings Include:

1. Observation made on January 8, 2019, at 1:05 p.m., revealed the delayed egress lock at the stair tower outside room 101, lacked signage indicating Push Until Alarm Sounds, Door will Release in 15-seconds, lower level Homestead Unit.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed required signage was not installed.







 Plan of Correction - To be completed: 02/28/2019

Facility will install approved signage to stair tower egress lock outside RM 101 to indicate push until alarm sounds, door will release in appropriate time frame.

A quarterly audit will be conducted to ensure all required egress signage is present and in good shape. Results of this will be shared in monthly QI meeting.
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: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stair enclosures with a fire resistance rating, affecting 1 of two stair enclosures.

Findings Include:

1. Observation made on January 8, 2019, at 1:09 p.m., revealed there was an opening around a wire penetration sealed with a red caulking material, above the ceiling at the stair outside room 101. Adjacent to the penetration, there was caulk around wire penetrations extending from the wall, lower level Homestead.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed there were openings in the stair enclosure.





 Plan of Correction - To be completed: 02/28/2019

Penetration will be sealed with an approved through penetration fire stop system (1WL1016) that will be on file in the Maintenance shop.

A quarterly penetration audit will be conducted throughout center to identify and correct any penetrations found.
Results will be shared in monthly QI meeting.
NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain exit discharges to a public way, affecting 1 of three exits from this building component.

Findings Include:

1. Observation made on January 8, 2019, at 1:35 p.m., revealed the exit discharge by room 118 leads down a grassy hill. The exit lacks a solid compact surface to the public way to traverse during inclement weather, lower level south tower.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed an unobstructed exit path was not provided.






 Plan of Correction - To be completed: 03/08/2019

A new ADA compliant exit discharge walkway will be installed that connects the building exit to the main parking lot / sidewalk area.

All other building exit discharged areas will be checked for compliance. Results of the audit will be share in monthly QI meeting.

We will submit plan of construction of walkway to DOH for prior approval.
NFPA 101 STANDARD Corridor - 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.
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: BUILDING 02 (SOUTH WING) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors with positive self-latching and smoke tight resistance along the means of egress, affecting 2 of four smoke compartments within this building component.

Findings Include:

1. Observation made on January 8, 2019, at 1:20 p.m., revealed there was approximately a 1/2" inch gap between the side of the corridor door and the frame to room 109 when closed, lower level Homestead.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed the corridor door was not smoke tight in its frame.


2. Observation made on January 8, 2019, at 1:45 p.m., revealed there was paper inside the housekeeping closet corridor door keeper plate, preventing the door from positively latching into its frame, upper level south.

Exit Interview with the Facility Administrator, Director of Maintenance and the Maintenance Supervisor on January 8, 2019, at 2:30 p.m., confirmed the corridor door would not latch into its frame.










 Plan of Correction - To be completed: 02/28/2019

Maintenance will repair door to be smoke tight and positively latched.

Maintenance will complete door audit quarterly to ensure all doors latch positively within frame.


2. Maintenance will complete a in-service to housekeeping staff on items obstructing latch keeper from correct operation.

Maintenance will complete door audit quarterly to ensure all doors latch positively within frame.




Initial comments:Name: BUILDING 03 (NORTH BUILDING) - Component: 03 - Tag: 0000


Facility ID# 024202
Component 03
North Wing

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2019, at The Belvedere Center, Genesis Healthcare- North Wing, it was determined there were no deficiencies identified under the 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 two-story, Type II (000), unprotected non-combustible construction, with is fully sprinklered.


 Plan of Correction:



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