Pennsylvania Department of Health
SOUTHWESTERN NURSING AND REHABILITATION CENTER
Building Inspection Results

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SOUTHWESTERN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  40 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.
SOUTHWESTERN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on a revisit to an Emergency Preparedness Survey completed on December 11, 2023, it was determined that Southwestern Nursing and Rehabilitation was in substantial compliance with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 452302
Component 01
Main Building

Based on revisit to a Medicare/Medicaid Recertification Survey completed on December 11, 2023, it was determined that Southwestern Nursing Care 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 (222), fire resistive building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 two instances, affecting the entire facility


Findings Include:

1. Review of documentation on December 11, 2023, revealed the facility lacked documentation for the following inspections:

a) 8:30 a.m., an annual fire alarm inspection;
b) 8:35 a.m., a semi-annual visual fire alarm inspection.

Interview with the Facility Administrator and Maintenance Director on December 11, 2023, at 8:35 a.m., confirmed the fire alarm system deficiencies.

****Note: During the revisit on January 31, 2024, between 8:30 a.m. and 10:00 a.m., the item 1b fire alarm deficiency was determined not to be completed.

Interview with Facility Administrator and Maintenance Director on January 31, 2024, at 10:00 a.m., confirmed the fire alarm deficiency.





 Plan of Correction - To be completed: 03/05/2024

Facility will ensure documentation is available for the required annual fire alarm inspection

The Maintenance staff will be in-serviced on required paperwork concerning the fire alarm panel and systems.

The Director of Maintenance or designee will audit the life safety log book to ensure all required paperwork is present monthly time 3 months.

Results of the audit will be reviewed by QAPI committee for recommendations.
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to complete the required four-year test and inspection of all smoke dampers throughout the facility.

Findings include:

1. Review of documentation on December 11, 2023, at 8:40 a.m., revealed there was no evidence that smoke dampers throughout the building had been inspected or tested in the last 48 months. Visual observation of the dampers revealed no inspection labels.

Interview with the Facility Administrator and Maintenance Director on December 11, 2023, at 8:40 a.m., confirmed the lack of documentation at the time of the survey.


****Note: During the revisit on January 31, 2024, between 8:30 a.m. and 10:00 a.m., the damper inspection was completed; however, the deficiencies found during the inspection were not corrected.

Interview with Facility Administrator and Maintenance Director on January 31, 2024, at 10:00 a.m., confirmed the fire damper deficiencies.




 Plan of Correction - To be completed: 03/05/2024

Facility will ensure that the fire damper deficiencies found during the inspection are corrected and repaired.

The maintenance staff will be in-serviced on the requirements for fire damper inspections.

The director of maintenance or designee will audit the required paperwork for the fire dampers monthly times 3 months.

Results of the audit will be reviewed by the QAPI committee for recommendations.

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