Nursing Investigation Results -

Pennsylvania Department of Health
ROSEWOOD GARDENS REHABILITATION AND NURSING CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSEWOOD GARDENS REHABILITATION AND NURSING CENTER
Inspection Results For:

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ROSEWOOD GARDENS REHABILITATION AND NURSING 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 10, 2019, it was determined that Broomall Presbyterian Village had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.


 Plan of Correction:


483.73(b)(8) REQUIREMENT Roles Under a Waiver Declared by Secretary: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at 403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to develop policies and procedures to include the facility's role in providing alternate care at alternate care sites during emergencies, as part of their Emergency Preparedness plan, affecting the entire facility.

Findings Include:

1. Documentation review on April 10, 2019, between 8:30 am and 11:30 am, revealed the Emergency Preparedness plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver during a declared emergency.

Interview with the Administrator and Maintenance Director, at the exit conference on April 10, 2019, at 3:15 pm, confirmed confirmed the EP plan did not include a policy for the facility's role during a declared emergency, under the 1135 waiver.





 Plan of Correction - To be completed: 05/28/2019

Policy and procedure has been developed to provide alternate care at alternate care sites during emergencies.

This procedure has been placed in the emergency preparedness book.

Transfer agreements have been reviewed for appropriateness.

Staff education will be provided on their role in providing care and treatment at alternate care sites during a declared emergency.

Administrator/designee will review semi- annually compliance with appropriate transfer agreements and staff education and update as needed.
Information will be presented at QAPI meeting for review and further discussion.
Initial comments:Name: MAIN BUILDING 01 (A & B & CENTRAL WINGS) - Component: 01 - Tag: 0000


Facility ID# 283202
Component 01
A, B, & Central Wings

Based on a Medicare/Medicaid Recertification Survey completed on April 10, 2019, it was determined that Broomall Presbyterian Village - A, B, & Central Wings 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 III (200), unprotected, ordinary construction, with an attic, partial basement, and basement-level crawl space, which is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 (A & B & CENTRAL WINGS) - Component: 01 - Tag: 0211

Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of four smoke compartments within this facility.

Findings include:

1. Observation made on April 10, 2019, at 1:35 pm, revealed A-wing door by rooms 101 and 100 leading to an exterior court yard area, could be mistaken for exit, lacked signage indicating Not an Exit.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, on April 10, 2019, at 3:20 pm, confirmed the missing signage.






 Plan of Correction - To be completed: 05/28/2019

1. On 4/10/19 an "not an exit" sign was placed on the door leading to the exterior court yard area on A-wing.
2. Maintenance will monitor exit doors for proper signage monthly and report findings to QAPI for 3 months.

NFPA 101 STANDARD Sprinkler System - Supervisory Signals: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.
Sprinkler System - Supervisory Signals
Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired.
9.7.2.1, NFPA 72
Observations:
Name: MAIN BUILDING 01 (A & B & CENTRAL WINGS) - Component: 01 - Tag: 0352

Based on observation, document review and interview, it was determined the facility failed to ensure automatic sprinkler system supervisory signals were installed and monitored, affecting the entire facility.

Findings include:

1. Observation made on April 10, 2019, at 2:30 pm, revealed the sprinkler system control valve, located in the exterior sprinkler pit, lacked electronic supervision. In addition, the pit access was not locked.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, confirmed the unsupervised sprinkler control valve and access to the pit was not locked.














 Plan of Correction - To be completed: 05/28/2019

Harrisburg plan review department was contacted, William Gutches, and confirmation was received that a plan will be needed for installation of the new fire alarm component. We are in process of registering for plan review and submission of plans.
1. A. Installation of monitoring system of the sprinkler system control valve to ensure it provides signal that sounds and is displaced at continuously allotted location or approved remote facility when sprinkler operation is impaired.
B- Sprinkler pit has been locked to prohibit unauthorized access.
2. Maintenance director and staff will be in-serviced on checking water level, securing of protective covers to prevent damage to alarm mechanisms and ensure sprinkler pit access door is properly locked.
3. Maintenance director/designee will audit facility weekly for four weeks and monthly for 3 months and findings will be reported to monthly 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 (A & B & CENTRAL WINGS) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the ceiling assemblies to be smoke tight and identification of sprinkler system components in place, affecting two of four smoke compartments.

Findings Include:

1. Observation made on April 10, 2019, between 1:40 pm and 2:15 pm, revealed ceiling assemblies that were not smoke resistant, at the following locations:
a. 1:40 pm, A-wing above the juice and beverage machines, unsealed penetration of the monolithic ceiling around 2" inch sprinkler branch;
b. 2:15 pm, B-wing day room by room 216 high hat, recessed light fixture was dislodged.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, confirmed the non-smoke resistant ceiling assemblies at the above named locations.


2. Observation made on April 10, 2019, at 2:35 pm, revealed the exterior sprinkler system fire department connection signage was not in place.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, confirmed the missing signage.
















 Plan of Correction - To be completed: 05/28/2019

1. A. The area on A-wing above the juice machine will be sealed with an approved fire rated UL design number for the interior drywall penetration to ensure the fire rated assembly is maintained.
B. On B-wing a new high hat light fixture assembly will be installed.
2. Signage will be placed on the exterior sprinkler system fire department connection.
3. Maintenance Staff will audit monthly for 3 months or during projects to ensure the penetration are sealed per code and that signage remains in place. Will report monthly to QAPI for further discussion or intervention.

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 (A & B & CENTRAL WINGS) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings to positively latch, affecting one of four smoke compartments within this component.

Findings Include:

1. Obseravtion made on April 10, 2019, at 2:05 pm, revealed B-wing room 208 door failed to positively latch into its frame.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, confirmed the door failed to latch.







 Plan of Correction - To be completed: 05/28/2019

1. The door on B-wing to room 208 had been fixed to positively latch into its frame
2.Maintenance staff will monitor monthly for 3 months and report at the monthly QAPI meeting their findings.

NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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 - 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: MAIN BUILDING 01 (A & B & CENTRAL WINGS) - Component: 01 - Tag: 0921

Based on documentation and interview, it was determined the facility failed to maintain inspection of electrical wiring and receptacle systems, affecting all resident bed locations within the facility.

Findings include:
1. Review of documentation on April 10, 2019, between 8:30 am and 11:30 am, 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).

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, confirmed the test was not performed.












 Plan of Correction - To be completed: 05/28/2019

1. All receptacles in resident care rooms will be inspected: visually, correct polarity and retention force of the grounding blade.
2. Receptacle inspections will be conducted annually in patient care areas by maintenance staff.
3. Maintenance director or designee will audit to ensure proper functioning receptacles in resident care rooms. Findings will be reported to QAPI meeting for further discussion and intervention.

Initial comments:Name: BUILDING 02 (C, D, AND E WINGS) - Component: 02 - Tag: 0000


Facility ID# 283202
Component 02
C, D and E Wings

Based on a Medicare/Medicaid Recertification Survey completed on April 10, 2019, it was determined that Broomall Presbyterian Village - C, D and E Wings were 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 483.70(a).

This is a two story, Type II (000), unprotected, noncombustible construction, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BUILDING 02 (C, D, AND E WINGS) - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of six smoke compartments within this facility.

Findings include:

1. Observation made on April 10, 2019, at 2:55 pm, revealed the exit pathway from the PT room into the little courtyard, could be mistaken for an exit. The area lacked signage indicating Not an Exit.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, on April 10, 2019, at 3:20 pm, confirmed the missing signage.





 Plan of Correction - To be completed: 05/28/2019

1. On 4/24/19 an "not an exit" sign was placed on both doors leading to the little court yard area from the PT room.
2. Maintenance will monitor exit doors for proper signage monthly and report findings to QAPI for 3 months.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: BUILDING 02 (C, D, AND E WINGS) - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to ensure exits were readily accessible at all times, affecting one of six smoke compartments within this component.

Findings include:

1. Observation made on April 10, 2019, at 1:35 pm, revealed the second floor E wing stair tower #1, the exit discharge door to the outside was difficult to open and required an excessive amount of force.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, on April 10, 2019, confirmed the door was hard to open.











 Plan of Correction - To be completed: 05/28/2019

1. The second floor E-wing stair tower #1 will be adjusted to utilize minimal force to open.
2. Maintenance staff will monitor doors for ease of opening monthly for three months and report at monthly QAPI their findings.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: BUILDING 02 (C, D, AND E WINGS) - Component: 02 - Tag: 0355

Based on obseravtion and interview, it was determined the facility failed to maintain portable fire extinguishers in operable condition, wnich could affect the entire facility.

Findings include:

1. Observation made on April 10, 2019, at 1:00 pm, revealed the K-type fire extinguisher within the kitchen was missing an operating pin and safety seal.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, on April 10, 2019, at 3:20 pm, confirmed the missing fire extinguisher components.









 Plan of Correction - To be completed: 05/28/2019

1- a new safety pin and safety seal were placed on the K-type fire extinguisher for the kitchen.
2-A sweep of all fire extinguishers has been conducted to ensure all fire extinguishers are in operable condition.
3-Maintenance director or designee will audit fire extinguishers monthly to ensure proper operable condition and report findings to QAPI meeting for further discussion.

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: BUILDING 02 (C, D, AND E WINGS) - Component: 02 - Tag: 0374

Based upon observation and interview, it was determined the facility failed to maintain smoke barrier door assemblies smoke tight, affecting one of six smoke compartments within this facility.

Findings include:

1. Observation made on April 10, 2019, at 2:12 p.m., revealed the E-wing smoke barrier doors at the resident dining room would not close smoke tight into their corresponding door frame assembly.

Interview with the Administrator and Director of Maintenance at the exit interview on April 10, 2019, at 3:20 pm, confirmed barrier doors failed to close completely.










 Plan of Correction - To be completed: 05/28/2019

1-The E-wing smoke barrier doors have been adjusted to properly close into their corresponding door frame assembly.
2-Maintenance staff will monitor and audit monthly to ensure the smoke barrier doors close properly into their frames to maintain a smoke barrier and report at monthly QAPI meeting for further discussion or intervention.


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