Pennsylvania Department of Health
YARDLEY REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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YARDLEY REHABILITATION AND HEALTHCARE 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 February 29, 2024, at Yardley Rehabilitation and Healthcare 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 #125802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 29, 2024, it was determined that Yardley Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 V (111), protected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of five smoke compartments.

Findings include:

Observation on February 29, 2024, at 9:19 a.m., revealed the self-closing door to the south nourishment room would not self-close and latch in its frame when tested.

Interview with the Facility Administrator and the Maintenance Director on February 29, 2024, at 12:30 p.m., confirmed the listed self-closing door deficiency.

Plan of Correction - To be completed: 03/20/2024

1) Door identified has had door self-closure repaired.

2) NHA will educate Maintenance director to ensure doors to smoke barriers, or hazardous area enclosure areas self-close and are kept in the closed position, unless held open by a release device complying with regulations.

3) Weekly audits for one month will be conducted by Maintenace Director/Designee on smoke barrier or hazardous area enclosure doors to ensure compliance. Monthly audits x 3 thereafter will be conducted. Findings will be presented at QAPI for review.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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, it was determined the facility failed to maintain hazardous area enclosures in two instances, affecting one of five smoke compartments.

Findings include:

Observation on February 29, 2024, revealed the facility failed to maintain the required one-hour fire rating in the following hazardous area enclosure locations:

a) 8:48 a.m., the door to the clean side of the laundry room failed to self-close and latch in its frame when tested:
b) 8:50 a.m., the door to the kitchen dry storage room located in the service hallway failed to self-close and latch in its frame when tested.

Interview with the Facility Administrator and the Maintenance Director on February 29, 2024, at 12:30 p.m., confirmed the listed hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 03/20/2024

1) Both doors identified have had self-closures repaired. Doors latch and close properly.

2) NHA will educate Maintenance director to ensure doors to smoke barriers, or hazardous area enclosure areas self-close and are kept in the closed position, unless held open by a release device complying with regulations.

3) Weekly audits for one month will be conducted by Maintenace Director/Designee on smoke barrier or hazardous area enclosure doors to ensure compliance. Monthly audits x 3 thereafter will be conducted. Findings will be presented at QAPI for review.

NFPA 101 STANDARD Cooking Facilities:

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 the facility failed to install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of five smoke compartments. In accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1.

Findings include:

Observation on February 29, 2024, at 8:58 a.m., revealed the wheeled gas-fired oven/cook-top located on the cooking line in the kitchen was not equipped with an approved method that would ensure that the appliance was returned to an approved design location under the kitchen hood extinguishing system after it had been moved for maintenance and cleaning.

Interview with the Facility Administrator and the Maintenance Director on February 29, 2024, at 12:30 p.m., confirmed the listed kitchen hood extinguishing system deficiency.

Plan of Correction - To be completed: 03/20/2024

1) A Dormont Manufacturing PS 2 SAFETY-SET POSITIONING SYSTEM has been ordered and will be installed immediately once received.

2) NHA will educate Maintenance director to ensure equipment installed is protected by the kitchen hood extinguishing system

3) Weekly audits for one month will be conducted by Maintenace Director/Designee to ensure the wheeled gas-fired oven/cook-top located on the cooking lines is returned to an approved under the kitchen hood extinguishing system after it had been moved for maintenance and cleaning. Monthly audits x 3 thereafter will be conducted. Findings will be presented at QAPI for review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting three of five smoke compartments.

Findings include:

Observation on February 29, 2024, revealed the following automatic sprinkler system
deficiencies:

a) 8:45 a.m., there were two sprinkler heads behind the dryers in the laundry room that were covered in lint:
b) 8:48 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the kitchen dry storage room located in the service hallway:
c) 9:51 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were unsealed conduit penetrations in the ceiling above the electrical cabinets in the north day room storage room.

Interview with the Facility Administrator and the Maintenance Director on February 29, 2024, at 12:30 p.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 03/20/2024

1) The two sprinkler heads behind the dryers in the laundry room have been cleaned. Storage has been moved below 18 inches. Conduit penetrations in the ceiling above the electrical cabinets in the north day room storage room have been repaired.

2) NHA will educate maintenance director on Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems.

3) Weekly audits for one month will be conducted by Maintenance Director/Designee on Sprinkler Heads, in laundry room and sample of storage locations to ensure compliance. Monthly audits x 3 thereafter will be conducted. Findings will be presented at QAPI for review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in two instances, affecting four of five smoke compartments.

Findings include:

Observation on February 29, 2024, revealed the following smoke barrier wall deficiencies:

a) 9:19 a.m., observation above the ceiling at the smoke barrier doors by resident room 101 revealed there were unsealed data wires in the smoke barrier wall:
b) 9:47 a.m., observation above the ceiling at the smoke barrier doors by resident room 313 revealed there were unsealed data wires in the smoke barrier wall:

Interview with the Facility Administrator and the Maintenance Director on February 29, 2024, at 12:30 p.m., confirmed the listed smoke barrier wall deficiencies.

Plan of Correction - To be completed: 03/20/2024

1) Fire stop has been put in place to correct the unsealed smoke barrier doors identified.

2) NHA will educate maintenance director on ensuring no smoke barrier penetrations.

3) Weekly audits for one month will be conducted by Maintenance Director/Designee on a sample of smoke barrier locations to ensure no penetrations. Monthly audits x 3 thereafter will be conducted. Findings will be presented at QAPI for review.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of five smoke compartments.

Findings include:

Observation on February 29, 2024, at 9:10 a.m., revealed there was a microwave and a refrigerator plugged into a power strip in the business office.

Interview with the Facility Administrator and the Maintenance Director on February 29, 2024, at 12:30 p.m., confirmed the listed electrical wiring system and equipment deficiency.

Plan of Correction - To be completed: 03/20/2024

1) Power strip has been removed from business office.

2) NHA will educate maintenance director to ensure compliance with power strips and extension cords.

3) Weekly audits for one month will be conducted by Maintenance Director/Designee on a sample of rooms to ensure compliance. Monthly audits x 3 thereafter will be conducted. Findings will be presented at QAPI for review.

Initial comments:Name: WEST SIDE 24 BED ADDITION - Component: 02 - Tag: 0000

Facility ID# 125802
Component 02
West Side 24-bed Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 29, 2024, at Yardley Rehabilitation and Healthcare Center, it was determined there were no deficiencies identified under the 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 V (111), protected wood frame building, that is fully sprinklered.

Plan of Correction:

Initial comments:Name: EAST SIDE 4 BED ADDITION - Component: 03 - Tag: 0000

Facility ID# 125802
Component 03
East Side 4-bed Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 29, 2024, at Yardley Rehabilitation and Healthcare Center, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing 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 V (111), protected wood frame building, that is fully sprinklered.

Plan of Correction:

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