Nursing Investigation Results -

Pennsylvania Department of Health
OLD ORCHARD HEALTH CARE CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OLD ORCHARD HEALTH CARE CENTER
Inspection Results For:

There are  25 surveys for this facility. Please select a date to view the survey results.

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OLD ORCHARD HEALTH CARE 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 30, 2019, at Old Orchard Health Care 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# 09350200
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2019, it was determined that Old Orchard Health Care 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 two story, Type II (111), protected, noncombustible building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview, the facility failed to maintain the required regulations set forth by Pennsylvania Act 48 for one of one carbon monoxide policy.

Findings include:

1. Document review on January 30, 2019, at 11:00 a.m., revealed the facility lacked a carbon monoxide detector policy, to include evacuation and alarm protocols.

Interview with the maintenance director on January 30, 2019, at 11:00 a.m., confirmed a carbon monoxide policy was not available at the time of inspection.




 Plan of Correction - To be completed: 03/15/2019

1. CO detector policy to be created and kept in the facility life safety manual.
2. The maintenance director/designee will reconcile existing CO detector use with policy.
3. The Maintenance Director/Designee will do random audits of CO detectors throughout the facility to make sure that they remain in compliance. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.

NFPA 101 STANDARD Building Construction Type and Height:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain building construction, within a one hour fire rated ceiling assembly, at one of eleven wings.

Findings include:

1. Observation on January 30, 2019, at 11:20 a.m., revealed the second floor, corridor recessed ceiling light fixture, located between the smoke barrier and the lounge, lacked proper bonneting to maintain the fire rating of the ceiling assembly.

Interview with the maintenance director on January 30, 2019, at 11:20 a.m., confirmed the above recessed ceiling light lacked required bonneting.




 Plan of Correction - To be completed: 03/15/2019

1. Light fixture will have bonneting installed and made to be complete.
2. The maintenance director/designee will ensure bonneting is in place for all like fixtures.
3. The maintenance director/designee will do random audits of light fixtures throughout the facility to make sure that they remain in regulatory compliance. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary

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 January 30, 2019, at 1:50 p.m., revealed the first floor, resident room 130, had an excessive amount of combustibles stored inside the room (over forty cardboard boxes, as well as plastic bins and a large amount of clothing).

Interview with the maintenance director on January 30, 2019, at 1:50 p.m., confirmed the above resident room had an excessive amount of combustibles.






 Plan of Correction - To be completed: 03/15/2019

1. The excessive cardboard boxes and bins will be removed from the resident room with careplan intervention.
2. The maintenance director/designee will work with nursing and social services to ensure that careplanned hoarding behaviors do not create an unsafe environment or combustible hazard.
3. The maintenance director/designee will do random audits of room 130 to make sure that an excessive amount of combustibles does not occur. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.

NFPA 101 STANDARD Sprinkler System - 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.
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, the facility failed to maintain fire sprinkler systems for one of one sprinkler system.

Findings include:

1. Observation on January 30, 2019, at 1:00 p.m., revealed the facility lacked a stock of spare sprinklers for every type in the building (specifically, upright-type).

Interview with the maintenance director on January 30, 2019, at 1:00 p.m., confirmed there were not spares for the upright-type sprinklers.



 Plan of Correction - To be completed: 03/15/2019

1. The facility sprinkler contractor has been contacted and spare sprinkler heads have been ordered.
2. The maintenance director/designee will ensure that a stock of spare sprinkler heads exists for each type in the facility currently installed.
3. The maintenance director/designee will do random audits of sprinkler head spare stock to make sure that appropriate spares exist for each type found in the facility. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, the facility failed to maintain portable fire extinguishers in two of eleven wings.

Findings include:

1. Observation on January 30, 2019, between 11:45 a.m., and 2:15 p.m., revealed blocked access to the following corridor fire extinguishers:
a. (11:45 a.m.) second floor, corridor near resident room 227, obstructed by a lift.
b. (2:15 p.m.) first floor, corridor near resident room 160, obstructed with a large chair.

Interview with the maintenance director on January 30, 2019, at 2:15 p.m., confirmed the above portable fire extinguishers were obstructed.





 Plan of Correction - To be completed: 03/15/2019

1. A-Lift was removed at time of survey 1/31/2019 B-Chair was removed at time of survey 1/31/2019.
2. The maintenance director/designee will ensure that there is no blocked access to fire extinguishers throughout the facility.
3. The maintenance director/designee will do random audits of fire extinguisher access points to ensure lack of obstruction. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.

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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, the facility failed to maintain smoke barrier doors in one of six smoke partitions.

Findings include:

1. Observation on January 30, 2019, at 1:15 p.m., revealed the first floor, smoke barrier doors, near unit #1 personal laundry, did not completely close in the frame.

Interview with the maintenance director on January 30, 2019, at 1:15 p.m., confirmed the above smoke barrier doors did not close completely in the frame.





 Plan of Correction - To be completed: 03/15/2019

1. The door will be adjusted to close and latch into frame-Completed 2/1/19
2. The maintenance director/designee will ensure that all smoke doors close and latch into their frames.
3. The maintenance director/designee will do random audits of smoke doors throughout the facility to ensure closing and latching. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain electrical systems in one of over 100 rooms.

Findings include:

1. Observation on January 30, 2019, at 1:30 p.m., revealed the first floor, ancillary storage room, had two carts containing boxes blocking access to the electrical panels.

Reference: NFPA 70, 2011 edition, section 110.26.

Interview with the maintenance director on January 30, 2019, at 1:30 p.m., confirmed blocked access to the above electrical panels.



 Plan of Correction - To be completed: 03/15/2019

1. The carts were removed at time of survey-Completed on 1/31/19
2. The maintenance director/designee will ensure that no carts block access to electrical panels.
3. The maintenance director/designee will do random audits of electrical panel access points to ensure clearance. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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, the facility failed to maintain electrical equipment in two of over 100 rooms.

Findings include:

1. Observation on January 30, 2019, between 11:25 a.m. and 11:30 a.m., revealed the following second floor, resident rooms, were utilizing extension cords:
a. (11:25 a.m.) resident room 201.
b. (11:30 a.m.) resident room 205.

Interview with the maintenance director on January 30, 2019, at 11:30 a.m., confirmed the above rooms were utilizing extension cords.





 Plan of Correction - To be completed: 03/15/2019

1. A&B - The extension cords were removed at time of survey-Completed on 1/31/19
2. The maintenance director/designee will ensure that no extension cords are in use in resident rooms.
3. The maintenance director/designee will do random audits of resident rooms to ensure no extension cords are in use. Any trends will be reported in Quality Assurance and Performance Improvement committee for further action and planning, if necessary.


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