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

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MONROEVILLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  41 surveys for this facility. Please select a date to view the survey results.

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MONROEVILLE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on January 17, 2024, at Monroeville Skilled Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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

Facility ID# 076502
Component 01
Main building

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that Skilled Nursing and Rehabilitation Services-Monroeville 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 II (111), protected noncombustible building, without a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on observation and interview, it was determined the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of five smoke compartments.

Findings Include:

1. Observation on January 17, 2024, at 8:45 a.m., revealed a gas-fired range on wheels, in the main kitchen, was not provided with an approved method that would ensure the appliance was returned to an approved design location after it had been moved for maintenance and cleaning, as required by section 12.1.2.3 and 12.1.2.3.1 of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Interview with the Facility Administrator and Maintenance Director on January 17, 2024, at 11:00 a.m., confirmed the gas-fired cooking appliance was not tethered in a way so it could not be moved from the ventilation hood and gas connection.



 Plan of Correction - To be completed: 03/17/2024

Cooking appliance will be tethered in a way so that it can not be moved from the ventilation hood and gas connection. Administrator will educate the respected departments identified on the education sign in sheet that the cooking appliance must be tethered to prevent being moved from the gas and ventilation connection. A one time audit will take place by the Nursing Home Administrator/designee to assure the cooking equipment is tethered properly. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on January 17, 2024, at 8:35 a.m., revealed the facility lacked documentation verifying that any sprinkler inspections were performed in the last twelve months.

Interview with the Facility Administrator and Maintenance Director on January 17, 2024, at 8:35 a.m., confirmed the facility lacked documentation for sprinkler inspections.



 Plan of Correction - To be completed: 03/17/2024

The required sprinkler inspections will be performed based on the twelve month period regulation. The facility will have the proper documentation for the sprinkler system inspections once they are completed and will be filed in the Life Safety book. Administrator will educate the respected departments identified on the education sign in sheet that the sprinkler inspections must take place and be documented in the Life Safety book within the 12 month period per the regulation. A one time audit will take place by the Nursing Home Administrator/designee to assure the sprinkler inspections were in fact completed and the proper documentation supporting this is on file. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

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 in two instances, affecting two of five smoke compartments.

Findings include:

1. Observation on January 17, 2024, revealed the following corridor door deficiencies:

a) 8:50 a.m., revealed the door to resident room #127 failed to latch when tested;
b) 9:30 a.m., revealed the door to resident room #211 failed to latch when tested.

Interview with the Facility Administrator and the Director of Maintenance on January 17, 2024, at 11:00 a.m., confirmed the corridor door deficiencies.




 Plan of Correction - To be completed: 03/17/2024

Doors on resident rooms 127 and 211 will be fixed, so that they properly latch according ot the regulation for corridor doors. Administrator will educate the respected departments identified on the education sign in sheet that corridor doors must latch properly per the regulation for corridor doors. An audit completed by the Administrator will take place twice a week for 4 weeks then once a month thereafter to ensure that corridor doors shut properly. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform two of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on January 17, 2024, at 8:30 a.m., revealed the facility lacked fire drill documentation for the third shift in the first quarter and the second shift for the third quarter.

Interview with the Facility Administrator and Maintenance Director on January 17, 2024, at 8:30 a.m., confirmed the facility lacked documentation for the drills between January and March, and July through September in 2023.





 Plan of Correction - To be completed: 03/17/2024

Facility will conduct fire drills per the regulation and have proper fire drill documentation in the Life Safety book for all shifts in 2024. Administrator will educate the respected departments identified on the education sign in sheet that file drills must take place each quarter on all three shifts per the regulation as well as the proper documentation filed in the Life Safety book for the fire drills completed. Facility Maintenance Director will complete an audit for each fire drill completed and filed in the Life Safety book. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

NFPA 101 STANDARD Electrical Systems - Maintenance 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914
Based on documentation review and interview, it was determined that the facility failed to maintain electrical receptacles in patient sleeping areas, affecting the entire facility.

Findings include:

1. Documentation review on January 17, 2024, at 9:35 a.m., revealed the facility lacked documentation for an annual tension and continuity test of non-hospital grade electrical receptacles in the patient sleeping rooms of the facility.

Interview with the Facility Administrator and Maintenance Director on January 17 , 2024, at 9:35 a.m., confirmed the facility lacked documentation for an annual test of non-hospital grade electrical receptacles in patient sleeping areas, performed within the last 12 months.



 Plan of Correction - To be completed: 03/17/2024

The receptacle tests per the regulation will be completed and the proper documentation for the tests will be filed in the Life Safety book. Administrator will educate the respected departments identified on the education sign in sheet that receptacle tests must be completed annually per the regulation and the documentation for the tests must be filed in the Life Safety book. Facility Maintenance Director will complete an audit for each receptacle test that was completed in 2024. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on January 17, 2024, at 9:00 a.m., revealed the facility lacked documentation verifying that the emergency generator weekly and monthly testing, annual load bank and the yearly preventative maintenance was performed.

Interview with the Facility Administrator and Maintenance Director, on January 17 ,2024, at 9:00 a.m., confirmed the required monthly, weekly, and yearly generator testing documentation was not available at the time of the survey.



 Plan of Correction - To be completed: 03/17/2024

Generator tests, weekly, monthly and annually will be conducted by the facility Maintenance Director per the regulation and the test documentation will be filed properly in the Life Safety book. Generator tests planned to be completed in January 2024 both weekly and monthly. Administrator will educate the respected departments identified on the education sign in sheet that the generator tests must be completed weekly, monthly and annually per the regulation and the test documentation must be filed properly in the Life Safety book. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

Initial comments:Name: THERAPY ADDITION - Component: 02 - Tag: 0000

Facility ID# 076502
Component 02
P.T. Addition
Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, at Skilled Nursing and Rehabilitation Services-Monroeville, 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 II (111), protected noncombustible building, without a basement, that is fully sprinklered.





 Plan of Correction:


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: THERAPY ADDITION - Component: 02 - Tag: 0353
Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on January 17, 2024, at 8:35 a.m., revealed the facility lacked documentation verifying that any sprinkler inspections were performed in the last twelve months.

Interview with the Facility Administrator and Maintenance Director on January 17, 2024, at 8:35 a.m., confirmed the facility lacked documentation for sprinkler inspections.



 Plan of Correction - To be completed: 03/17/2024

The required sprinkler inspections will be performed based on the twelve month period regulation. The facility will have the proper documentation for the sprinkler system inspections once they are completed and will be filed in the Life Safety book. Administrator will educate the respected departments identified on the education sign in sheet that the sprinkler inspections must take place and be documented in the Life Safety book within the 12 month period per the regulation. A one time audit will take place by the Nursing Home Administrator/designee to assure the sprinkler inspections were in fact completed and the proper documentation supporting this is on file. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: THERAPY ADDITION - Component: 02 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform two of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on January 17, 2024, at 8:30 a.m., revealed the facility lacked fire drill documentation for the third shift in the first quarter and the second shift for the third quarter.

Interview with the Facility Administrator and Maintenance Director on January 17, 2024, at 8:30 a.m., confirmed the facility lacked documentation for the drills between January and March, and July through September in 2023.




 Plan of Correction - To be completed: 03/17/2024

Facility will conduct fire drills per the regulation and have proper fire drill documentation in the Life Safety book for all shifts in 2024. Administrator will educate the respected departments identified on the education sign in sheet that file drills must take place each quarter on all three shifts per the regulation as well as the proper documentation filed in the Life Safety book for the fire drills completed. Facility Maintenance Director will complete an audit for each fire drill completed and filed in the Life Safety book. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: THERAPY ADDITION - Component: 02 - Tag: 0918
Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on January 17, 2024, at 9:00 a.m., revealed the facility lacked documentation verifying that the emergency generator weekly and monthly testing, annual load bank and the yearly preventative maintenance was performed.

Interview with the Facility Administrator and Maintenance Director, on January 17 ,2024, at 9:00 a.m., confirmed the required monthly, weekly, and yearly generator testing documentation was not available at the time of the survey.



 Plan of Correction - To be completed: 03/17/2024

Generator tests, weekly, monthly and annually will be conducted by the facility Maintenance Director per the regulation and the test documentation will be filed properly in the Life Safety book. Administrator will educate the respected departments identified on the education sign in sheet that the generator tests must be completed weekly, monthly and annually per the regulation and the test documentation must be filed properly in the Life Safety book. Results of this safety check will be taken to the monthly quality assurance meeting to be reviewed for quality and accuracy.



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