Pennsylvania Department of Health
WESTON REHABILITATION & NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WESTON REHABILITATION & 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 February 27, 2024, at Weston Rehabilitation & Nursing 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# 390202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined that Weston Rehabilitation & Nursing 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 one story, Type III (200), unprotected, ordinary building, with two partial basements, basement-level crawl space, and unused attic space, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain one common wall in three instances, affecting one of two floors.

Findings include:

1. Observation on February 27, 2024, between 10:12 a.m., and 10:15 a.m., revealed the following:

a. 10:12 a.m., the common wall door with the Dietary Department portion of the business occupancy building required adjustment to fully latch.
b. 10:13 a.m., the common wall door with the Storage Room portion of the business occupancy building required adjustment to fully latch.
c. 10:15 a.m., the common wall door with the Storage Room portion of the business occupancy building lacked fire-rated hardware.

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the common wall deficiencies.

Plan of Correction - To be completed: 04/03/2024

1) The Maintenance Director and necessary other were in-serviced by the Administrator as to the requirement and importance surrounding door latching and properly installing hardware.
The common wall doors in the dietary department and storage rooms were adjusted to latch properly, and the hardware on the storage room door properly secured.
An audit will be conducted by the Maintenance Director every 2 weeks for 2 months, to ensure proper door latching and door knob hardware is installed properly and in working order.
2) This deficiency, plan of correction and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

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.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide two acceptable means of egress, affecting two of four smoke compartments within the facility.

Findings include:

1. Observation on February 27, 2024, at 10:00 a.m., revealed both the basement boiler room/pressure tank room and the basement laundry/storage room locations lacked a second acceptable means of egress.

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the acceptable means of egress deficiency.

Plan of Correction - To be completed: 04/03/2024

Request made to Department of Health – Division of Safety Inspection to complete Fire Safety Evaluation System (FSES).

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in one instance, affecting two of two floors.

Findings include:

1. Observation on February 27, 2024, at 10:45 a.m., revealed the facility lacked annual fire alarm inspection data (the facility did supply annual, visual fire alarm inspection data, dated 4/2023).

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the fire alarm inspection deficiency.

Plan of Correction - To be completed: 04/03/2024

1) The Maintenance Director as necessary other were in-serviced by the Administrator as to the requirement and importance surrounding having timely fire alarm system inspections scheduled and conducted.
The company that performed the last inspection (date correction) 2/2023, was contacted, and are scheduled to perform necessary inspection and testing of the fire alarm system April 5th, 2024, starting at 8:00am; their earliest availability.
The Maintenance Director going forward, will create a tracking tool, and schedule future inspections of systems in the facility required annually, bi-annually, and other intervals as necessary, to prevent future occurrences of the same.
2) This deficiency, plan of correction, and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

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 documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in multiple instances, affecting two of two floors.

Findings include:

1. Observation on February 27, 2024, between 9:57 a.m., and 10:31 a.m., revealed the following:

a. 9:57 a.m., storage items were located within eighteen inches of an adjacent automatic sprinkler head within the Supplies Closet.
b. 10:31 a.m., penetrations of the ceiling assembly, located within the basement-level, Wheelchair Storage.

2. Observation of facility documentation on February 27, 2024, between 10:57 a.m., and 11:07 a.m., revealed the following:

a. 10:57 a.m., the facility lacked three of four, previous, quarterly sprinkler inspections (sprinkler report, dated 2/21/23, was supplied).
b. 10:58 a.m., the facility lacked five year, internal valve and internal pipe testing data, as well as five year sprinkler gauge replacement (or recalibration).
c. 10:59 a.m., the facility lacked required, three year, internal tank inspection data.
d. 11:00 a.m., the yearly, automatic sprinkler report, dated 2/21/23, listed the following deficiencies: "sprinkler heads in the kitchen are corroded." "Dry barrels are from 1976." "Need 2 FDC signs." "sprinkler heads in the kitchen are mixed temperatures, Link and GB." "No check valve on air line." "System due for five year internal and 3 year air leak test." Tank due for five year inspection."

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the automatic sprinkler deficiencies.

Plan of Correction - To be completed: 04/03/2024

1) The Maintenance Director as necessary other were in-serviced by the Administrator as to the requirement and importance surrounding having timely annual sprinkler and associated system inspections scheduled and conducted.
The company that performed the last inspection (date correction) 2/2023, was contacted, and are scheduled to perform necessary inspection and testing of the sprinkler and associated systems April 5th, 2024, starting at 8:00am; their earliest availability.
The Maintenance Director going forward, will create a tracking tool, and schedule future inspections of systems in the facility required annually, bi-annually, and other intervals as necessary, to prevent future occurrences of the same.
2) This deficiency, plan of correction, and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of two floors.

Findings include:

1. Observation on February 27, 2024, at 10:09 a.m., revealed the Dining Room smoke barrier separation door required adjustment to fully latch.

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the smoke barrier separation door deficiency.

Plan of Correction - To be completed: 04/03/2024

1) The Maintenance Director and necessary other were in-serviced by the Administrator as to the requirement and importance surrounding proper fire door alignment.
The ante-dining room double doors were adjusted for proper closing in the event of a power loss or the fire alarm being activated.
An audit will be conducted by the Maintenance Director every 2 weeks for 2 months, to ensure proper door alignment of fire doors in the facility.
2) This deficiency, plan of correction and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting two of two floors.

Findings include:

1. Observation on February 27, 2024, at 10:50 a.m., revealed the facility lacked a natural gas reliability letter.

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the generator set deficiency.

Plan of Correction - To be completed: 04/03/2024

1) The Maintenance Director and necessary other were in-serviced by the Administrator as to the requirement and importance surrounding being in possession of a gas company "Natural Gas Reliability Letter".
A letter was requested from UGI Utilities, and the facility is awaiting its arrival.
An audit/review of the letter will be conducted by the Maintenance Director to determine when a further request for a similar letter will be necessary.
2) This deficiency, plan of correction and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc:

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 - Component: 01 - Tag: 0921

Based on documentation review and interview, it was determined the facility failed to maintain electrical systems in multiple locations, affecting one of two floors.

Findings include:

1. Observation on February 27, 2024, at 10:55 a.m., revealed the facility lacked annual receptacle testing data.

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the receptacle testing data deficiency.

Plan of Correction - To be completed: 04/03/2024

1) The Maintenance Director and necessary other were in-serviced by the Administrator as to the requirement and importance surrounding documenting electrical receptacle condition and operability.
The Maintenance Director has composed an improved tracking tool to better document and archive his electrical receptacle inspection rounds.
An audit will be conducted by the Maintenance Director every 2 weeks for 2 months, to ensure electrical receptacles are not only inspected, but documented using this new tool.
2) This deficiency, plan of correction and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of two floors.

Findings include:

1. Observation on February 27, 2024, at 10:23 a.m., revealed two unsecured oxygen cylinders, located at the basement level.

Exit interview with the Facilities Manager on February 27, 2024, between 11:15 a.m., and 11:30 a.m., confirmed the cylinder storage deficiency.

Plan of Correction - To be completed: 04/03/2024

1) All nursing staff, housekeeping, and necessary others were in-serviced by the Administrator as to the requirement and importance surrounding proper oxygen tank safety and management.
The oxygen tanks identified by the surveyor were immediately secured.
An audit will be conducted by the Director of Nursing every 2 times a week for 1 month, to ensure proper oxygen tank discipline is adhered to.
2) This deficiency, plan of correction and related corrective measures to include audits, will be submitted to our QAPI Committee for review to determine effectiveness, adequacy or need for necessary change.

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