Nursing Investigation Results -

Pennsylvania Department of Health
SANATOGA CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SANATOGA CENTER
Inspection Results For:

There are  28 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.
SANATOGA 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 April 22, 2019, at Sanatoga 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# 233702
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2019, it was determined that Sanatoga 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 two-story, Type II (111), protected, non-combustible structure, with an attic, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating for building construction, affecting two of seven smoke compartments.

Findings include:

1. Observation on April 22, 2019, between 12:00 pm, and 2:15 pm, revealed unsealed penetrations of the fire rated ceiling, in the following locations:

a. 12:00 pm, 2nd floor Chapel storage room, around a bundle of cables;
b. 2:15 pm, 1st floor Electric Room, around a bundle of wires.

Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the unsealed penetrations.







 Plan of Correction - To be completed: 06/03/2019

The facility is working with regional support to obtain proper fire stop system for the penetration in the second floor chapel storage room around a bundle of cables and the first floor electric room around wires.
The maintenance director or designee will monitor for unsealed penetrations of the fire rated ceiling. The maintenance director or designee will audit the checks scheduled through the TELs maintenance system.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.

NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to ensure emergency lighting was tested at required intervals, affecting the entire facility.

Findings include:

1. Document review on April 22, 2019, at 9:40 am, revealed, documentation verifying an annual 90-minute test of the battery back-up lighting was not available at time of survey.

Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 06/03/2019

The 90 minute test of the battery backup lighting was completed.
The maintenance director or designee added the task to the TELs maintenance system for completion of annual test.
The maintenance director or designee will audit schedule of annual inspections.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.

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 observation and interview, it was determined the facility failed to maintain sprinkler system components without obstructions, affecting one of two stair towers.

Findings include:

1. Observation on April 22, 2019, at 1:45 pm, revealed, inside the 1st floor front stair tower, there was a sprinkler with paint on the bulb.

Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the paint on the sprinkler.






 Plan of Correction - To be completed: 06/03/2019

The sprinkler head in the first floor front stair tower is scheduled to be replaced.
The maintenance director or designee will monitor first floor front stair tower sprinkler head for cleanliness.
Preventative maintenance is scheduled for maintenance director or designee to check sprinkler heads.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch in their frames, affecting one of two levels.

Findings include:

1. Observation on April 22, 2019, between 12:25 pm, and 12:30 pm, revealed the following corridor doors failed to close and positively latch when tested:

a. 12:25 pm, 2nd floor resident room 225;
b. 12:30 pm, 2nd floor resident room 218.

Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the doors failed to close and latch when tested.





 Plan of Correction - To be completed: 06/03/2019

The second floor resident room 225 and second floor resident room 218 corridor doors were adjusted to close and positively latch.

The maintenance director or designee will inspect second floor resident room doors to close and positively latch.
The maintenance director or designee will randomly audit resident room doors for closing and positively latching.
The audit results will be reviewed monthly x3 by the facility QAPI 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 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 the fire resistance rating of the smoke barrier walls, affecting one of two levels.

Findings include:

1. Observation on April 22, 2019, at 11:45 am, revealed, above the suspended ceiling inside the 1st floor elevator corridor, there was an unsealed penetration around a sprinkler pipe.

Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the unsealed penetration.




 Plan of Correction - To be completed: 06/03/2019

The penetration above the suspended ceiling inside the first floor elevator has been sealed using a UL rated approved fire barrier through wall fire stop system. W-L 1016.

The maintenance director or designee will monitor the suspended ceiling in the first floor elevator corridor for penetrations.

Preventative maintenance is scheduled through the TELs system to monitor smoke barriers throughout the facility.

The audit results will be reviewed monthly x3 by the facility QAPI Committee.

NFPA 101 STANDARD Electrical Systems - Receptacles: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 Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain protection of electric equipment in wet locations, affecting one of seven smoke compartments.

Findings include:

1. Observation on April 22, 2019, at 12:10 pm, revealed, inside the 2nd floor Physical Therapy Department, there was a hydrocollator plugged into a non Ground Fault Circuit Interrupter (GFCI) receptacle.

Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the hydrocollator was not plugged into a GFCI receptacle.




 Plan of Correction - To be completed: 06/03/2019

The receptacle in the physical therapy department second floor has been replaced with an interrupter (GFCI receptacle).

The maintenance director or designee will complete a walk through to ensure all proper receptacles are in place.

The audit results will be reviewed monthly x3 by the facility QAPI Committee.


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