Nursing Investigation Results -

Pennsylvania Department of Health
LUTHERAN COMMUNITY AT TELFORD
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHERAN COMMUNITY AT TELFORD
Inspection Results For:

There are  17 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.
LUTHERAN COMMUNITY AT TELFORD - 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 April 29, 2019, at Lutheran Community at Telford, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: NEW HEALTH CENTER - Component: 04 - Tag: 0000


Facility ID# 124502
Component 04
New Health Center

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2019, it was determined that Lutheran Community at Telford, 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 four-story, Type II (222), fire resistive structure, with two lower levels, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: NEW HEALTH CENTER - Component: 04 - Tag: 0355

Based on documentation review and interview it was determined the facility failed to maintain portable fire extinguishers affecting all fire extinguishers within the facility.

Findings include:

1. Review documentation on April 29, 2019, between 8:30 a.m. and 10:30 a.m., revealed the facility lacked the required certification of the inspector performing the annual inspection of fire extinguishers.

Exit interview with the Administrator and Director of Maintenance on April 29, 2019, at 2:45 p.m., confirmed the lack documentation.








 Plan of Correction - To be completed: 06/12/2019

Certification for the inspector that performed the annual inspection of fire extinguishers was obtained.

Going forward, certification will be requested when inspection is scheduled.

Monitored by Director of Maintenance or designee.
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: NEW HEALTH CENTER - Component: 04 - Tag: 0372

Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the smoke barrier walls affecting one of fourteen smoke compartments within this facility.

Findings include:

Observation made on April 29, 2019, at 1:30 pm, revealed that 3rd floor smoke barrier wall at room 311, had a partially sealed penetration around 3/4" inch conduit sleeve.

Exit interview with the Administrator and Director of Maintenance on April 29, 2019, at 2:45 p.m., confirmed the penetration.



 Plan of Correction - To be completed: 06/12/2019

The partially sealed penetration around the 3/4" conduit sleeve on the 3rd floor barrier wall at room 311 will be sealed with 3M CP25WB+ caulk per system No.W-L-1016.

When work is performed affecting smoke barrier walls it will be inspected upon completion.

Monitored by Director of Maintenance or designee.
NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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 - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: NEW HEALTH CENTER - Component: 04 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems affecting three of four floors within this facility.
Findings include:
1. Review of documentation on April 29, 2019, between 8:30 a.m. and 10:30 a.m., revealed the required annual inspection of receptacles in patient care areas was not performed.

Receptacle testing should include the following:
a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit interview with the Administrator and Director of Maintenance on April 29, 2019, at 2:45 p.m., confirmed the test was not performed.









 Plan of Correction - To be completed: 06/12/2019

Receptacle testing will be completed and documented as per regulation.

Monitored by Director of Maintenance or designee.

A task to be completed yearly will be created in our electronic prevention maintenance program to ensure testing has been completed.

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