Pennsylvania Department of Health
ANN'S CHOICE
Building Inspection Results

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ANN'S CHOICE
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

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ANN'S CHOICE - 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 2, 2024, at Ann's Choice, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.






 Plan of Correction:


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


Facility ID# 18860201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 2, 2024, it was determined that Ann's Choice 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 three-story, Type II (222), fire resistive construction, with basement and unused attic spaces, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
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 - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting one of four levels.

Findings include:

1. Document review on January 2, 2024, at 8:30 a.m., revealed the facility could not provide documentation of a semi-annual kitchen hood ansul suppression system inspection within 6 months of 9/26/2023.

Exit interview with the Administrator and the Maintenance Supervisor on January 2, 2024, at 10:45 a.m., confirmed the lack of documentation.


2. Observation on January 2, 2024, at 10:21 a.m., revealed in the basement Kitchen, the kitchen hood suppression system lacked monthly visual inspections.

Exit interview with the Administrator and the Maintenance Supervisor on January 2, 2024, at 10:45 a.m., confirmed the missing inspections.






 Plan of Correction - To be completed: 02/19/2024

1. The kitchen hood ansul suppression system was inspected on 9/26/23. The system's next inspection is due March 2024 and has been scheduled.
2. Security Manager or designee will audit the inspections of the kitchen hood suppression system to ensure they are in compliance with the regulation.
3. Security Manager or designee will educate the security team to ensure that the kitchen hood suppression system is visually inspected monthly and a semi-annual kitchen hood ansul suppression system is completed.
4. Results of audits will be presented at the monthly Continuing Care QAPI meeting x 3 months.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting one of two inspections.

Findings include:

Document review on January 2, 2024, at 8:30 a.m., revealed the facility could not provide documentation of a semi-annual fire alarm visual inspection within 6 months of 8/22/2023.

Exit interview with the Administrator and the Maintenance Supervisor on January 2, 2024, at 10:45 a.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/19/2024

1. The semi-annual fire alarm visual inspection is scheduled for February 2024.
2. Security Manager or designee will audit the documentation to ensure a semi-annual visual fire alarm inspection is completed.
3. The Security Manager or designee will educate the security team to ensure a semi-annual visual fire alarm inspection is completed.
4. Results of audits will be presented at the monthly Continuing Care QAPI meeting x 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511
Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of four levels in the facility.

Findings include:

Observation on January 2, 2023, at 10:05 a.m., revealed on the first floor, an unsecured junction box above the ceiling outside CSU.

Exit interview with the Administrator and the Maintenance Supervisor on January 2, 2024, at 10:45 a.m., confirmed the unsecured junction box.





 Plan of Correction - To be completed: 02/19/2024

1. The junction box was secured to the wall on the 1st floor above the ceiling outside of the CSU.
2. Maintenance Supervisor or designee will audit junction boxes in the ceiling to ensure junction boxes are secured.
3. Maintenance Supervisor or designee will educate Maintenance team to ensure junction boxes are secured in the ceiling.
4. Maintenance Supervisor or designee will audit junction boxes monthly x 3 months to ensure they are secured.
5. Results of audits will be presented at the monthly Continuing Care QAPI meeting x 3 months.

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: MAIN BUILDING - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain gas equipment storage, affecting one of four levels in the facility.

Findings include:

Observation on January 2, 2024, at 10:07 a.m., revealed on the first floor, the Oxygen Storage room lacked signage stating: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Exit interview with the Administrator and the Maintenance Supervisor on January 2, 2024, at 10:45 a.m., confirmed the lack of signage.





 Plan of Correction - To be completed: 02/19/2024

1. A No-Smoking sign was immediately placed on the Oxygen Storage Room door.
2. NHA or designee will educate employees that the signage of No Smoking must remain on the Oxygen Storage Room at all times.
3. Maintenance Supervisor or designee will audit the Oxygen Storage Room door weekly x 12 weeks to ensure No-Smoking sign is present.
4. Results of audits will be presented at the monthly Continuing Care QAPI meeting x 3 months.


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