Nursing Investigation Results -

Pennsylvania Department of Health
PLEASANT RIDGE MANOR- WEST
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PLEASANT RIDGE MANOR- WEST
Inspection Results For:

There are  36 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.
PLEASANT RIDGE MANOR- WEST - 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 13-14, 2019, it was determined that Pleasant Ridge Manor-West, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.





 Plan of Correction:


483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients: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.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness Plan to include sharing the facilities' Emergency Preparedness Plan with existing resident's families or representatives, in one of one plans.

Findings include:

Document review on February 13, 2019, at 10:30 a.m., revealed at the time of survey, the facility lacked documentation verifying the facilty had shared the facilities' Emergency Preparedness Plan with existing residents' families or representatives.

Interview with the risk manager on February 13, 2019, at 10:30 a.m., confirmed the facility lacked documentation verifying the facilty had shared the facilities' Emergency Preparedness Plan with existing residents' families or representatives.




 Plan of Correction - To be completed: 03/01/2019

Preparation and/or evaluation of the following Plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiency. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Pleasant Ridge Manor will distribute notifications of its disaster plan via a section in the Pleasant Ridge Manor Newsletter which is mailed and/or delivered to all current residents, resident families and/or contacts. The Newsletter is scheduled to be mailed on February 28th, 2019.

Pleasant Emergency Preparedness Fact Sheet is posted at Unit Nurse's Stations.

Pleasant Ridge Manor will continue to include the Emergency Preparedness Fact Sheet in the Admission Packets for all new incoming residents.

Quarterly Quality Assurance checks will be done by the Risk Manager and/or designee to assure compliance that required information is in Admission Packets and the mailing was completed.

Documentation of the mailed list will be documented and retained.

Initial comments:Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0000


Facility ID # 311002
Component 03
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2019, it was determined that Pleasant Ridge Manor-West, 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 three-story, Type II (222), fire resistive building, that 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: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0161

Based on observation and interview it was determined that the facility failed to maintain the structural steel fireproofing for a Type II (222) building, on one of four levels.

Findings include:

Observation on February 13, 2019, at 12:20 p.m., revealed the second floor stairwell, by room #212, had a structural steel beam, above the stairwell door, on the corridor side, that lacked spray on fire proofing, on the lower section of the structural beam, approximately four feet in length.

Interview with the director of environmental services and the maintenance supervisor on February 13, 2019, at 12:20 p.m., confirmed the second floor stairwell, by room #212, had a structural steel beam, above the stairwell door, on the corridor side, that lacked spray on fire proofing, on the lower section of the structural beam, approximately four feet in length.




 Plan of Correction - To be completed: 03/01/2019

The beam will be fire coated with an approved fire rated material by an outside contractor.

The Maintenance Department will continue to check for un-coated steel beams when doing the semi - annual Preventive Maintenance Program that checks for penetrations.

This will be added to the monthly Quality Assurance monitor that checks for penetrations and will be completed by Maintenance Staff and monitored by the Director of Environmental Services and/or designee.

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: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0211

Based on observation and interview it was determined that the facility failed to maintain the means of egress free of obstructions, on one of four levels.

Findings include:

Observation on February 14, 2019, at 9:20 a.m., revealed the ground floor, maintenance shop, telephone room, had a two step locking arrangement on the room egress door, that would delay egress during an emergency.

Interview with the director of environmental services and maintenance supervisor on February 14, 2019, at 9:20 a.m., confirmed the ground floor, maintenance shop, telephone room, had a two step locking arrangement on the room egress door, that would delay egress during an emergency.





 Plan of Correction - To be completed: 03/01/2019

The two (2) step lock will be removed and replaced with a single step lock.

A monthly Quality Assurance Program monitor will be completed by Maintenance Staff to ensure there are appropriate locking devices in the facility. It will be monitored by the Director of Environmental Services and/or designee.

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: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0353


Based on observation and interview it was determined that the facility failed to maintain the automatic sprinkler system, on one of four levels.

Findings include:

1. Observation on February 14, 2019, between 8:40 a.m. and 10:10 a.m., revealed the following automatic sprinkler deficiencies:
A. (8:40 a.m.) Ground floor, security rear office, had two gaps in the ceiling tile, around pipes, that would delay the operation of the automatic sprinkler system.
B. (8:42 a.m.) Ground floor, female staff locker room, had a sprinkler escutcheon hanging below the lay-in ceiling assembly.
C. (9:40 a.m.) Ground floor, main pharmacy, had eleven windows that extended above the lay-in ceiling, with an open penetration between the window and the lay-in ceiling assembly that would delay the operation of the automatic sprinkler system.
D. (9:50 a.m.) Ground floor, pharmacy store room, had one window that extended above the lay-in ceiling with an open penetration between the window and lay-in ceiling assembly that would delay the operation of the automatic sprinkler system.
E. (9:07 a.m.) Ground floor, therapy office, had had two gaps around a wall mounted electrical panel box and the lay-in ceiling assembly and around a pipe that penetrated the lay-in ceiling assembly, inside the office doorway, that would delay the operation of the automatic sprinkler system.
F. (9:25 a.m.) Ground floor, main corridor, by the laundry stairwell, above the lay-in ceiling, had a sprinkler drain valve that lacked an approved metal sign.
G. (9:26 a.m.) Ground floor, laundry cart storage room, had one window that extended above the lay-in ceiling, with an open penetration between the window and lay-in ceiling assembly, that would delay the operation of the automatic sprinkler system.
H. (10:10 a.m.) Ground floor, main resident dining room, had an unsealed penetration in the lay-in ceiling, behind a large ventilation duct, due to a missing ceiling tile.

Interview with the director of environmental services and the maintenance supervisor on February 14, 2019, at 10:10 a.m., confirmed the automatic sprinkler system deficiencies listed above existed.








 Plan of Correction - To be completed: 03/01/2019

A. The gaps in the Ground Floor
Security Office around the pipes
will be sealed with fire rated
material.

B. The sprinkler escutcheon in the
female staff locker room will be
adjusted so it will not hand below
the lay in ceiling assembly.

C. The eleven (11) windows in the
Pharmacy Department will be
sealed above the existing lay in ceil ceiling with fire rated material.

D. The windows in the Pharmacy
storeroom will be sealed above
the existing lay in ceiling with fire
rated material.

E. The Ground floor Therapy office
window, electrical panel box,
and ceiling will be sealed with fire rated material.

F. The sprinkler drain valve by the
Laundry stairwell will be labeled
with a metal tag.

G. The windows and ceiling in the
Laundry Cart Storage Room will
be sealed with fire rated material.

H. Ceiling tiles will be installed
behind the ventilation ducts in
Main Resident Dining Room.

The Maintenance Department will
continue to check for penetrations,
unlabeled sprinkler drains and
missing ceiling tiles when completing
the semi-annual Preventive
Maintenance Program for
penetrations. Any items identified will
be addressed.

A monthly Quality Assurance monitor
will be completed by Maintenance
Staff and monitored by the Director
of Environmental Services and/or
designee to assure that items above
have been addressed and corrected.

NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0362

Based on observation and interview it was determined that the facility failed to maintain corridor smoke barriers as required per NFPA 101, 2012 edition, section 19.3.6.2.4, on one of four levels.

Findings include:

Observation on February 14, 2019, at 11:30 a.m., revealed the ground floor corridor, by room # J31, had a return air duct that terminated approximately twelve inches above the lay-in ceiling grid air diffuser, that would not resist the passage of smoke.

Interview with the director of environmental services and maintenance supervisor on February 14, 2019, at 11:30 a.m., confirmed the ground floor corridor, by room # J31, had a return air duct that terminated approximately twelve inches above the lay-in ceiling grid air diffuser, that would not resist the passage of smoke.





 Plan of Correction - To be completed: 03/01/2019

The return air duct will be connected to the diffuser by Room J31.

The Maintenance Department will continue to check to see if ductwork is terminated to resist the passage of smoke when completing the semi-annual Preventive Maintenance Program for penetrations. Any items identified will be addressed.

A monthly Quality Assurance monitor will be completed by Maintenance Staff and monitored by the Director of Environmental Services and/or designee to assure that items above have been addressed and corrected.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0918

Based on observation and interview it was determined that the facility failed to maintain and inspect the electrical system, on one of four levels.

Findings include:

Observation on February 14, 2019, at 9:10 a.m., revealed the ground floor corridor, at the smoke barrier wall, by the wheelchair storage room, above the lay-in ceiling, had a three to one electrical adapted plugged into an electrical outlet.

Interview with the director of environmental services and the maintenance supervisor on February 14, 2019, at 9:10 a.m., confirmed the ground floor corridor, at the smoke barrier wall, by the wheelchair storage room, above the lay-in ceiling, had a three to one electrical adapted plugged into an electrical outlet.





 Plan of Correction - To be completed: 03/01/2019

The three (3) into one (1) electrical adapter has been removed.

The Maintenance Department will continue to monitor for 3 to 1 adapters when doing the Quarterly Multiplexer Preventive Maintenance Program. All 3 to 1 electrical adapters will be removed.

A monthly Quality Assurance monitor will be completed by Maintenance Staff and monitored by the Director of Environmental Services and/or designee

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - 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: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0920

Base on observation and interivew it was determined that the facility failed to maintain and inspect powercords and extention cords, on one of four levels.

Finding include:

Observation on February 14, 2019, at 10:43 a.m., revealed the ground floor, room #K18 window bed, had a multiplug extenstion cord in use.

Interview with director of environmental services on February 14, 2019, at 10:43 a.m., confirmed the ground floor, room # K18 window bed, had a multiplug extenstion cord in use.





 Plan of Correction - To be completed: 03/01/2019

The multiple extension cord has been removed.

The Maintenance Department will continue to monitor for extension cords when doing the Quarterly Multiplexer Preventive Maintenance Program. All extension cords will be removed.


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