Nursing Investigation Results -

Pennsylvania Department of Health
CRESTVIEW CENTER
Building Inspection Results

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CRESTVIEW CENTER
Inspection Results For:

There are  34 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.
CRESTVIEW 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 January 22, 2019, it was determined that Crestview Center was not in compliance with 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, it was determined the facility failed to develop Policies and Procedures for the provisions of subsistence needs for residents and staff as part of the Emergency Preparedness (EP) plan, affecting the entire facility.

Findings Include:

1. Documentation review on January 22, 2019, revealed between 8:30 am and 11:00 am, the Emergency Preparedness plan did not include policies and procedures to ensure the subsistence needs for residents and staff for alternate source of energy.

Interview at the exit conference with the Administrator and Maintenance Director on January 22, 2019, at 3:00 pm, confirmed the EP plan did not include alternate source of energy.









 Plan of Correction - To be completed: 03/04/2018

1. Letter was immediately requested and received from our fuel supplier and currently in our Emergency Preparedness Plan.
2. Emergency Preparedness plan was reviewed to insure there all no other missing components required by regulation.
3. Maintenance Dir or designee will conduct audit using created audit tool
4. Maintenance Dir or designee will immediate report any deficiencies to the administrator
5. Maintenance Dir will report findings monthly to the QAPI Committee Meeting.

483.73(b)(8) REQUIREMENT Roles Under a Waiver Declared by Secretary: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. The [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:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at 403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to develop policies and procedures to include the facility's role in providing alternate care at alternate care sites during emergencies, as part of their Emergency Preparedness plan, affecting the entire facility.

Findings Include:

1. Documentation review on January 22, 2019, between 8:30 am and 11:00 am, revealed the Emergency Preparedness plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver during a declared emergency.

Interview at the exit conference with the Administrator and Maintenance Director on January 22, 2019, at 3:00 pm, confirmed the EP plan did not include a policy for the facility's role during a declared emergency, under the 1135 waiver.









 Plan of Correction - To be completed: 03/04/2019

1. Facility understands the importance of the Emergency Preparedness Plan addressing facility role in providing care and treatment at alternate care sites.
2. Administrator and Maintenance Dir reviewed the Emergency Preparedness Plan to identify further omissions with none found.
3. Administrator will reach out to neighboring facilities to create and enter a reciprocal care agreement for emergency.
4. Maintenance Dir will report progress and status of agreements to the monthly QAPI Committee meeting.
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 documentation review and interview, it was determined the facility failed to provide documentation of the development and maintenance of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures.

Findings include

1. Documentation review on January 22, 2019, between 8:30 am and 11:00 am, revealed the facility failed to provide documentation of an emergency preparedness training and testing program.

Interview at the exit conference with the the Administrator and Director of Maintenance on January 22, 2019, at 3:00 pm, confirmed the facility lacked a written Emergency Preparedness Plan to include a documented training and testing program.





 Plan of Correction - To be completed: 03/04/2019

1. Facility understands the importance of all employees having proper training on the contents and intent of our Emergency Preparedness Plan
2. Maintenance Dir and Administrator reviewed Emergency Preparedness Plan to create a program of in-servicing for all staff specific to the EPP.
3. Maintenance Dir and Administrator will educate all staff in EPP procedures and contents.
4. All new Hires will be provided with EPP education as a standard part of their orientation.
5. In-servicing compliance will be reports by the Maintenance Dir or designee to the monthly QAPI Committee meeting

483.73(d)(2) REQUIREMENT EP Testing Requirements:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on documentation review and interview, it was determined the facility failed to participate in a full-scale emergency preparedness exercise that was community-based.

Findings include:

1. Review of documentation on January 22, 2019, between 8:30 am and 11:00 am, revealed the facility lacked documented facility base table top exercise since the effective date of November 15, 2016.

Interview at the exit conference with the Administrator and the Maintenance Director on January 22, 2019 at 3:00 pm, confirmed documentation of a facility base drill was not provided as part of the Emergency Preparedness Plan.





 Plan of Correction - To be completed: 03/04/2019

1. Facility recognizes the importance of tabletop discussion to further prepare for emergency situations.
2. A tabletop discussion will be scheduled and completed to maintain regulatory compliance.
3. All staff will be in-serviced on the importance and the benefit to conducting tabletop discussions.
4. Maintenance Dir or Designee will appropriately track and document completion of the tabletop exercises.
5. Compliance will be reported to the monthly QAPI meeting by the maintenance dir or designee.

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


Facility ID# 030802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2019, it was determined that Crestview 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(000), unprotected wood frame construction, which is fully sprinklered.


 Plan of Correction:


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: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain exit discharges with hard packed all-weather travel surfaces, affecting two of four exit discharges.

Findings include:

1. Observation made on January 22, 2019, between 11:35 am and 1:10 pm, revealed the following exit discharges traversed through wet and muddy grass before reaching the public way:

a. 11:35 am, north wing;
b. 1:10 pm, east wing.

Interview at the exit conference with the Administrator and Director of Maintenance on January 22, 2019, at 3:00 pm, confirmed the condition of the exit discharges.




 Plan of Correction - To be completed: 03/22/2019

1. The facility understands the regulation which requires an exit with hard packed, all-weather travel surface. Facility will submit a Time Limited Waiver due to the current season and the need to accomplish in warmer temperatures.
2. Quotes have been requested to determine scope and expense for correcting two of the listed exits.
3. Upon receipt of quotes, project for addressing exits will be scheduled. Weather impacts project completion for appropriate install of concrete.
4. Maintenance Dir will report project status and progress to the administrator and to the monthly QAPI Committee Meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to ensure sprinklers system components were free of obstructions, affecting one of six smoke compartments within facility.

Findings include:

1. Observation made on January 22, 2019, at 1:45 pm, revealed a sprinkler head was fully recessed into a suspended ceiling tile in the east wing room 305, bed 1.

Interview at the exit conference with the Administrator and Director of Maintenance on January 22, 2019, at 3:00 pm, confirmed the sprinkler was recessed into the suspended ceiling tile.






 Plan of Correction - To be completed: 03/04/2019

1. Facility recognized the importance of insuring all sprinkler heads are free of obstruction. Repair of this sprinkler head scheduled immediately and corrected on 2/11/19.
2. All sprinkler heads have been inspected with no further problems.
3. All sprinkler heads will be audited monthly by the maintenance dir or designee to insure each is free from obstruction.
4. Maintenance director or designees will immediate report problematic issues to the administrator.
5. Audit findings will be reported to monthly QAPI meeting

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

Based on observation and interview, it was determined the facility failed to maintain corridor doors that positively self-latch into the frame, affecting one of six smoke compartments.

Findings include:

1. Observation on January 22, 2019, at 2:55 pm, revealed the clean linen storage room door was propped open by a linen cart.

Interview at the exit conference with the Administrator and the Maintenance Director on January 22, 2019, at 3:00 pm, confirmed the door was obstructed from closing.










 Plan of Correction - To be completed: 03/04/2019

1. The facility understands the importance of preventing any propping of doors. During the life safety inspection tour 1/22, both doors were closed and corrected immediately.
2. All doors were inspected to insure no door was propped open with no additional problems found.
3. Maintenance Director or designee will conduct audit monthly to insure no practice of propping doors.
4. Maintenance Dir or designee will report immediately any problematic issue to the administrator
5. Audit finding will be reported to the monthly QAPI Committee meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls, in two of six smoke compartments.

Findings include:

1. Observation made on January 22, 2019, between 1:45 pm and 1:55 pm, revealed the following smoke barrier wall had unsealed penetrations.

a. 1:45 pm, above the smoke barrier doors, at the human resources office, around a bundle of blue data wiring;
b. 1:55 pm, above the entrance door to physical therapy, around MC armored cables.

Interview at the exit conference with the Administrator and the Maintenance Director on January 22, 2019, at 3:00 pm, confirmed the unsealed penetrations.










 Plan of Correction - To be completed: 03/04/2019

1. Facility understands the safety importance of insuring no penetrations in smoke barrier walls. Repair of all smoke compartments was immediately scheduled and will be corrected on 2/21/19.
2. Audit of the entire facility found no additional penetrations.
3. Two penetrations found to be deficient were sealed with fire rated material to provide for building safety and regulatory compliance. The penetration in the smoke barrier walls were sealed with fire barrier caulk system, approved in UL through wall penetration, fire stop system. #W-L1016.
3. Maintenance Director or designee will conduct monthly audit to insure no penetration to the smoke barrier wall
4. Maintenance Director or designee will report problematic issues to the administrator immediately.
5. Audit findings will be reported to the monthly QAPI Committee Meeting.

NFPA 101 STANDARD Smoke Barrier Door Glazing: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.
Smoke Barrier Door Glazing
2012 EXISTING
Openings in smoke barrier doors shall be fire-rated glazing or wired glass panels in steel frames.
19.3.7.6, 19.3.7.6.2, 8.5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0379

Based on observation and interview, it was determined the facility failed to maintain door openings in smoke barrier walls, affecting two of six smoke compartments within this facility.

Findings include:

1. Observation made on January 22, 2019, at 1:55 pm, revealed the physical therapy door assembly, which is part of the smoke barrier wall, had tempered glass installed in lieu of fire-rated glazing or wired glass panels in steel frames

Interview at the exit conference with the Administrator and Maintenance Director on January 22, 2019, at 3:00 pm, confirmed the glass in the smoke barrier door was not fire-rated glazing or wired glass panels in steel frames.



 Plan of Correction - To be completed: 03/04/2019

1. Facility understands the safety importance to insuring all smoke doors with glass have proper fire rating.
2. Maintenance Dir inspected all doors with no further findings of glass issues
3. Shenker is scheduled to address these cited door by 2/15 and will schedule install of proper rated glass.
4. Maintenance Director will report any delay or problematic issue to the administrator and report completion to the monthly QAPI Committee Meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor electrical devices for unauthorized use, affecting one of six smoke compartments within this facility.

Findings include:

1. Observation made on January 22, 2019, at 2:25 pm, revealed a refrigerator and microwave were plugged into a surge protector within the activity office.

Interview at the exit conference with the Administrator and Maintenance Director on January 22, 2019 at 3:00 pm, confirmed the improper use of an electrical device.







 Plan of Correction - To be completed: 03/04/2019

1. Facility understands the importance of insuring surge protectors are not used inappropriately and the safety risks to non-compliance.
2. Surge protector was immediately removed by the maintenance director and activities staff counseled accordingly.
3. Monthly audit will be conducted by Maintenance Dir or designee to insure no unauthorized use of surge protectors.
4. Maintenance Director or designee will immediate report problematic issues to the administrator.
5. Audit findings will be reported to the monthly QAPI Committee meeting by the Maintenance Director.


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