Nursing Investigation Results -

Pennsylvania Department of Health
ELIZABETHTOWN HEALTHCARE AND REHAB CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ELIZABETHTOWN HEALTHCARE AND REHAB CENTER
Inspection Results For:

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ELIZABETHTOWN HEALTHCARE AND REHAB 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 March 7, 2019, at Elizabethtown Healthcare and Rehab Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: SNF - Component: 02 - Tag: 0000


Facility ID #123202
Component 02
New Building

Based on a Medicare/Medicaid Recertification Survey completed on March 7, 2019, it was determined that Elizabethtown Nursing and Rehabilitation 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 II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: SNF - Component: 02 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the common wall doors to positively latch, on one of two floors within the component.

Findings include:

1. Observation on March 7, 2019, at 12:00 PM revealed the double corridor fire rated doors separating the Nursing Care from Personal Care lacked parts from the latching hardware.

Interview with the Director of Maintenance on March 7, 2019, at 12:00 PM confirmed the door failed to positively latch.



 Plan of Correction - To be completed: 04/01/2019

The double corridor fire rated doors separating the Nursing Care from Personal Care now contains the latching hardware and the door latches properly.
The maintenance Director or designee will conduct an audit at and around the double corridor fire rated doors separating the Nursing Care from Personal to ensure latching hardware is there and all doors latch properly.
The maintenance director will conduct semiannual audits of the entire facility to ensure that all doors close properly and have the proper hardware installed.
The administrator will sign off on these audits only after he does a thorough investigation and walk around with the maintenance director to ensure the audit was accurate.
The director of maintenance will bring results to our monthly QAPI for further review.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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: SNF - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowed margins, be unobstructed from self-closing, and to be in good repair, and the ceiling to be smoke tight, on two of two floors within the component.

Findings include:

1. Observation on March 7, 2019, between 10:40 AM and 11:30 AM, revealed hazardous area doors exceeded the allowed gap margins, at the following locations:

a. 10:40 AM, ground floor, Maintenance Shop;
b. 11:30 AM, ground floor, Laundry.

Interview with the Director of Maintenance on March 7, 2019, at 11:30 AM confirmed hazardous area doors had gaps exceeding the allowed margins.


2. Observation on March 7, 2019, at 10:30 AM revealed a ceiling tile had been removed in basement Generator Room.

Interview with the Director of Maintenance on March 7, 2019, at 10:30 AM confirmed the ceiling was not smoke tight.


3. Observation on March 7, 2019, at 10:40 AM, revealed the Maintenance Shop door was held open with gallon containers, on the ground floor.

Interview with the Director of Maintenance on March 7, 2019, at 11:30 AM confirmed the door was obstructed from self-closing.


4. Observation on March 7, 2019, at 12:15 PM revealed the 1st floor Soiled-Linen Room door had unfilled holes where old hardware had been removed.

Interview with the Director of Maintenance on March 7, 2019, at 12:15 PM confirmed the door had penetrations.




 Plan of Correction - To be completed: 05/01/2019

1. Hazardous area doors exceeded the allowed gap margins, at the ground floor Maintenance Shop and the ground floor Laundry will be fixed to be within the allowed margins. The Ceiling tile that had been removed in the basement Generator Room has been replaced and Now is Smoke tight. the Maintenance Shop Door That was held open with gallon containers on the ground floor has been closed and is no longer obstructed from self-closing. The 1st floor Soiled-Linen Room door that had unfilled holes where old hardware had been removed has been fixed and no longer has penetrations.
2. The administrator or designee will observe on daily rounds all Door Margins, Ceiling tiles, Penetrations and self-closing fire doors to ensure that they are in compliance at all times.
3. The administrator or designee will provide education to the Maintenance personnel on Fire safety, maintaining hazardous area doors to be within the allowed margins, be unobstructed from self-closing, to be in good repair, and the ceiling to be smoke tight.
4. The administrator or designee will conduct Audits 5 days per week times 4 then 3 days a week for another 3 months on maintaining hazardous doors to be within the allowed margins, be unobstructed from self-closing, and to be in good repair, and the ceilings to be smoke tight. Deficient practice will be reported to the QAPI meetings for review and recommendations.




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: SNF - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, in approximately three of thirty-four doors within the component.

Findings include:

1. Observation on March 7, 2019, between 12:02 PM and 12:30 PM, revealed corridor doors failed to positively latch, at the following locations:

a. 12:02 PM, 1st floor, Dining Room;
b. 12:05 PM, 1st floor, Lounge;
c. 12:30 PM, 1st floor, Resident Room 123.

Interview with the Director of Maintenance on March 7, 2019, at 12:30 PM confirmed corridor doors failed to positively latch.





 Plan of Correction - To be completed: 04/01/2019

1A. The maintenance director fixed the following doors: a.1st floor, Dining Room; b. 1st floor, Lounge; c. 1st floor, Resident Room 123 and they now close properly and proper function Has been restored
1B. the maintenance director will do weekly rounds to make sure that all doors close properly.
2. The maintenance director will do a quarterly audit of the facility to ensure all doors positively latch per state and federal guidelines.
3.The facility will maintain compliance with fire precaution of all areas.
4. the maintenance director will present results of each audit to the administrator, the administrator will sign off only after he reviews for accuracy.
5. results of the audits will be presented monthly to the QA committee.


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: SNF - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors to be self-closing, on one of two floors within the component.

Findings include:

1. Observation on March 7, 2019, at 12:10 PM revealed the smoke barrier corridor door to the ground floor P/T was not closing and latching.

Interview with Director of Maintenance on March 7, 2019, at 12:10 PM confirmed the door failed to self-close.


2. Observation on March 7, 2019, at 12:12 PM revealed the smoke barrier door to the office of the ground floor P/T Office was block by furniture.

Interview with Director of Maintenance on March 7, 2019, at 12:12 PM confirmed the door was impeded from self-closing.



 Plan of Correction - To be completed: 04/15/2019

1. The smoke barrier corridor door to the ground floor P/T was adjusted for proper closure and now is latching properly/self-closing. The smoke barrier door to the office P/T Office that was block by furniture is now cleared from any blockage.
2. All latching doors in the facility were checked for proper closure.
3. Maintenance department staff shall be educated on the Life Safety Code
Requirements pertaining to deficiency.
4. Door checks shall be completed weekly for 4 weeks then monthly with the
results of the audits reported to the QAPI committee for review.

NFPA 101 STANDARD Electrical Equipment - Other: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 Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)
Observations:
Name: SNF - Component: 02 - Tag: 0919

Based on observation and interview, the facility failed to secure electrical panels from unathorized access, on two of two floors within the component.

Findings include:

1. Observation on March 7, 2019, at 11:15 AM revealed the wall-mounted recessed electrical panel, in the ground floor corridors, were unlocked and accessible to any unauthorized persons.

Interview with the Director of Maintenance on March 7, 2019, at 11:15 AM confirmed the unlocked electrical panel.




 Plan of Correction - To be completed: 04/01/2019

1A. The maintenance director secured all facility electrical panels from unauthorized access by installing locks in all Electrical panels within the facility.
1B. The maintenance director will do weekly rounds to make sure that all electrical panels are secured properly.
2. The maintenance director will do a quarterly audit of the facility to ensure all Electrical panels are secured per state and federal guidelines.
3. The maintenance director will present results of each audit to the administrator, the administrator will sign off only after he reviews for accuracy.
4. Results of the audits will be presented monthly to the QA committee.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: SNF - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to implement a system to separate full and empty medical gas tanks, on one of one floor within the component.

Findings include:

1. Observation on March 7, 2019, at 12:10 PM revealed the oxygen cylinders located in the 1st floor Clean Linen Room were not separated into full and empty categories, and there was one unsecured cylinder.

Interview with the Director of Maintenance on March 7, 2019, at 12:10 PM confirmed the medical gas tanks were not separated into full and empty.


 Plan of Correction - To be completed: 04/01/2019

1. The oxygen cylinders located in the 1st floor Clean Linen Room was separated into full and empty categories, and the one unsecured cylinder was immediately secured.
2. The Administrator or designee will implement a system to separate full and empty medical gas tanks by placing clear signs indicating were full oxygen cylinders are to be stored and where empty oxygen cylinders should be stored and provide an in-service to Nursing Staff on the new system implemented.
3. weekly rounds will be conducted with members of the IDT team together with the administrator to ensure that oxygen cylinders are in the proper place and in compliance with all state and federal regulations.
4. Audits of the oxygen cylinder storage room will be conducted 3X per week times 4 weeks to ensure compliance. Results of the weekly rounds will be brought to the QAPI committee for further review.


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