Pennsylvania Department of Health
RICHLAND HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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RICHLAND HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  43 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.
RICHLAND HEALTHCARE AND REHABILITATION 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 January 23, 2024, at Richland Healthcare and Rehabilitation 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# 440702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2024, it was determined that Richland Healthcare and Rehabilitation 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 V (000), unprotected wood frame building, without a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on January 23, 2024, at 9:33 a.m., revealed the facility failed to maintain the required one-hour fire rating in the soiled utility room B-wing side. When tested, the door would not seal in its frame and resist the passage of heat/smoke (there was a large gap at the top and side of the door).


Interview with the Facility Administrator and the Maintenance Supervisor on January 23, 2024, at 1:00 p.m., confirmed the listed hazardous area enclosure deficiency.





 Plan of Correction - To be completed: 02/21/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1.) The soiled utility room on B wing side was adjusted to seal in its frame and resist the passage of heat/smoke.
2.) Whole house audit of doors was completed to ensure that they seal in the frames and resist the passage of heat/smoke.
3.) Maintenance Director or Designee will audit doors weekly times 4 weeks and monthly for 3 months.
4.) Results will be reviewed at the Quality Assurance Performance Improvement meeting.

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 01 - Component: 01 - Tag: 0324

Based on observation and interview the facility failed to install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of seven smoke compartments. In accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1.

Findings include:

1. Observation on January 23, 2024, at 10:01 a.m., revealed the wheeled gas-fired oven/cook-top located on the cooking line in the kitchen was not equipped with an approved method that would ensure that the appliance was returned to an approved design location under the kitchen hood extinguishing system after it had been moved for maintenance and cleaning.


Interview with the Facility Administrator and the Maintenance Supervisor on January 23, 2024, at 1:00 p.m., confirmed the listed kitchen hood extinguishing system deficiency.







 Plan of Correction - To be completed: 02/21/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1.) Facility changed the wheels on the gas-fired oven/cook-top to legs so it is stationary under the kitchen hood extinguishing system.
2.) Maintenance Director or designee will audit the placement of the equipment under the kitchen hood extinguishing system weekly times 4 weeks and monthly times 3 months.
3.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.

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 the automatic sprinkler system in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on January 23, 2024, at 9:08 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were multiple unsealed penetrations in the ceiling of the A-wing housekeeping storage room.

Interview with the Facility Administrator and the Maintenance Supervisor on January 23, 2024, at 1:00 p.m., confirmed the listed automatic sprinkler system deficiency.





 Plan of Correction - To be completed: 02/21/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1.) Penetrations in the ceiling of the A-wing housekeeping storage room were sealed with 3M Fire Barrier Sealant CP25WB+.
2.) A facility review will be completed to check for penetrations
3.) Maintenance Director or designee will audit penetrations monthly for 3 months.
4.) Results of the audit will be reported at the Quality Assurance Performance Improvement meeting.

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

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of seven smoke compartments.

Findings include:

1. Observation on January 23, 2024, at 9:47 a.m., revealed the smoke barrier doors by the dining room would not fully close when tested and could not resist the passage of smoke.


Interview with the Facility Administrator and the Maintenance Supervisor on January 23, 2024, at 1:00 p.m., confirmed the listed smoke barrier doors deficiency.






 Plan of Correction - To be completed: 02/21/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1.) The smoke barrier doors by the dining room were adjusted to fully close when tested and could resist the passage of smoke.
2.) Smoke barrier doors were tested to ensure proper closing. Facility utilizes TELS for the monitoring of the smoke barrier doors closing and latching properly.
3.) Maintenance Director or designee will audit the smoke barrier/fire doors to ensure proper closing weekly times 3 weeks and monthly times 3 months.
4.) Results will be reviewed at the Quality Assurance Performance Improvement meeting.


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: MAIN BUILDING 01 - Component: 01 - Tag: 0920
Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on January 23, 2024, at 9:41 a.m., revealed a refrigerator plugged into a power strip in the activities room.


Interview with the Facility Administrator and the Maintenance Supervisor on January 23, 2024, at 1:00 p.m., confirmed the listed electrical wiring system and equipment deficiency.





 Plan of Correction - To be completed: 02/21/2024

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with all applicable state and regulatory requirements.

1.) The power strip in the activities room was immediately removed.
2.) A visual inspection of the facility will be completed to ensure no power strips are being used.
3.) Education provided to staff regarding not using power strips. Maintenance Director or designee will complete an audit of the facility to ensure no power strips are being used weekly times 3 weeks and monthly times 3 months.
4.) Results will be reviewed at the Quality Assurance Performance Improvement meeting.


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