Nursing Investigation Results -

Pennsylvania Department of Health
COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM
Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

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COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on February 27, 2019, it was determined that Country Meadows Nursing Center of Bethlehem, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(b)(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 documentation review and interview, it was determined the facility failed to provide documentation for the role of the facility under a waiver declared by the Secretary of the Department of Health.

Findings include:

1. Observation on February 27, 2019, at 10:55 a.m., revealed the facility lacked 1135 waiver documentation.

Exit interview with the facility administrator on February 27, 2019 between 11:15 a.m. and 11:30 a.m., confirmed the facility lacked 1135 waiver documentation.



 Plan of Correction - To be completed: 04/28/2019

I hereby acknowledge the CMS 2567-L issued to Country Meadows Nursing Center of Bethlehem for the survey date February 27,2019 and attest that the deficiencies listed will be corrected in a timely manner.

E 0026

Our Facility has developed and implemented policies and procedures that describe our role in providing care at alternate care sites during emergencies. We have collaborated with our local emergency officials in proactive planning to allow an organized and systematic response to assure continuity of care even when services at our facilities have been severely disrupted. Our Facility policies and procedures address what coordination efforts are required during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary.

In correction of this citation we have added an addendum to address the 1135 waiver within the Disaster Policy.

A written report of the deficiency with a POC will be submitted to QAPI and Corporate Compliance.

DISCLAIMER: The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the Facility's right to appeal and challenge the accuracy or severity of the alleged deficiencies or an admission of past of ongoing violations of State and Federal regulatory requirements.



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


Facility ID# 096802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2019, it was determined that Country Meadows Nursing Center of Bethlehem, 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 Multiple Occupancies - Contiguous Non-Health: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.
Multiple Occupancies - Contiguous Non-Health Care Occupancies
Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.4.1, 19.1.3.4.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0132

Based on observation and and interviw, it was determined the facility failed to maintain one common wall in two locations, affecting one of six smoke compartments.

Findings include:

1. Observation on February 27, 2019, between 9:50 a.m. and 9:52 a.m., revealed the following:
a. 9:50 a.m. The first floor, Dietary door, required adjustment in order to fully latch within the corresponding door frame assembly.
b. 9:52 a.m. The first floor, Dining Services door, required adjustment in order to fully latch within the corresponding door frame assembly.

Exit interview with the facility administrator on February 27, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the common wall deficiencies.



 Plan of Correction - To be completed: 04/28/2019

I hereby acknowledge the CMS 2567-L issued to Country Meadows Nursing Center of Bethlehem for the survey date February 27,2019 and attest that the deficiencies listed will be corrected in a timely manner.

K 0132

Self-closing devices were adjusted on the first floor Dietary door and the first floor Dining Services door. This was completed 2/27/2019.

All doors with self-closing latches were re-tested and operational.

Staff was re-in serviced on correct operational design of self-closing fire doors.

Maintenance supervisor will audit self-closing door monthly and adjust the closure valves as necessary.

The maintenance supervisor will report the findings of the audit to the quarterly QAPI Committee.

A written report of the deficiency with a POC will be submitted to QAPI and Corporate Compliance.

DISCLAIMER: The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the Facility's right to appeal and challenge the accuracy or severity of the alleged deficiencies or an admission of past of ongoing violations of State and Federal regulatory requirements.


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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of six smoke compartments.

Findings include:

1. Observation on February 27, 2019, at 10:35 a.m., revealed various wires atop branch sprinkler piping, within the first floor, Main Lobby.

Exit interview with the facility administrator on February 27, 2019, between 11:15 a.m. and 11:30 a.m. confirmed the automatic sprinkler system deficiency.



 Plan of Correction - To be completed: 04/28/2019

K0353

The various wires atop the branch sprinkler piping found within the first floor Main Lobby were drawn up and attached to the girders with ties.

A written report of the deficiency with a POC will be submitted to QAPI and Corporate Compliance.

DISCLAIMER: The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the Facility's right to appeal and challenge the accuracy or severity of the alleged deficiencies or an admission of past of ongoing violations of State and Federal regulatory requirements.

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, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting two of six smoke compartments.

Findings include:

1. Observation on February 27, 2019, at 9:40 a.m., revealed the first floor, Hallway C, smoke barrier separation door vision panel, lacked a screw.

Exit interview with the facility administrator on February 27, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the smoke barrier separation door deficiency.



 Plan of Correction - To be completed: 04/28/2019

K0374

The first floor C Hallway smoke barrier separation door that was lacking a screw was repaired.

All fire doors in the building were re-inspected.

Maintenance supervisor will continue to audit all smoke barrier separation doors yearly and perform repairs as necessary.

The maintenance supervisor will report the findings of the audit to the quarterly QAPI Committee.

A written report of the deficiency with a POC will be submitted to QAPI and Corporate Compliance.

DISCLAIMER: The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the Facility's right to appeal and challenge the accuracy or severity of the alleged deficiencies or an admission of past of ongoing violations of State and Federal regulatory requirements.



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