Nursing Investigation Results -

Pennsylvania Department of Health
LUTHER WOODS NURSING AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHER WOODS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  31 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.
LUTHER WOODS NURSING 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 April 16, 2019, it was determined that Luther Woods Nursing And Rehabilitation Center 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

Emergency Preparedness (EP) plan that included policies and procedures that include the facility's role in providing alternate care at alternate care sites during emergencies, affecting the entire facility.

Findings include:

1. Document review on April 16, 2019, between 8:45 am and 11:00 am, revealed the facility failed to develop an Emergency Preparedness Plan to include the role of the facility under a waiver declared by the Secretary of the Department of Health.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the Emergency Preparedness plan did not include a policy for the facility's role identified by emergency management officials.






 Plan of Correction - To be completed: 06/11/2019

New EPP is being written up including a policy regarding the facility's role identified by emergency management officials.
Local Emergency management coordinator has been contacted to review our EPP and policies.
Maintenance will monitor on an ongoing basis.
483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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 [facility] 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:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) communication plan for sharing information on occupancy needs, affecting the entire facility.

Findings include

1. Document review on April 16, 2019, between 8:45 am and 11:00 am, revealed the facility failed to provide documentation of an emergency plan that includes a means for providing information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, an Incident Command Center, or designee.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the facility lacked a written Emergency Preparedness plan did not include a means for providing information about its occupancy.




 Plan of Correction - To be completed: 06/11/2019

Local Emergency management coordinator has been contacted by the facility to provide information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, an Incident Command Center, or designee.
Maintenance will monitor on an ongoing basis based on the request of the emergency management coordinator.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 640302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 16, 2019, it was determined Luther Woods Nursing 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 III (200), unprotected ordinary structure, with partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain exit discharges with a hard packed travel surface, affecting three of three exit discharges.

Findings include:

1. Observation made on April 16, 2019, between 1:00 pm and 2:25 pm, revealed the following exit discharges lacked a hard compact surface before reaching the public. Egress was through wet and muddy grass:

a. 1:00 pm, A-wing by room 130 and 131;
b. 2:05 pm, B-wing by room 219.
c. 2:25 pm, C-wing exit across from television lounge.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the condition of the exit discharges.












 Plan of Correction - To be completed: 06/11/2019

A wing by room 130 and 131. B wing by room 219. C wing exit across from television lounge will be a solid level walking surface.

Contractors contacted.A time limited waiver will be needed to correct this deficiency.


Maintenance supervisor to monitor annually to ensure egress is passable per regulations.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 document review and interview, it was determined the facility failed to maintain operable components of the fire alarm system, affecting the entire facility.

Findings include:

1. Documents reviewed on April 16, 2019, between 8:30 am and 11:00 am, revealed the fire alarm inspection report dated March 22, 2019, stated the fire alarm control panel back-up batteries had an expired manufacturer date.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed documentation verifying correction was unavailable for review.














 Plan of Correction - To be completed: 06/11/2019

The fire alarm control panel back-up battery, that had an expired manufacturer date has been replaced.

Maintenance director will audit and document alarm control panel back-up batteries semi annually. To ensure no batteries are expired.

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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain doors with positive latching within their frames, free from impediments to closing, affecting two of four smoke compartments within this facility.

Findings include:

1. Observation made on April 16, 2019, between 2:00 pm and 2:25 pm, revealed the following corridor doors failed to close completely and positively latch into the frames:

a. 2:00 pm, A wing room 114;
b. 2:25 pm, B wing room 209.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the doors failed to positively latch.


2. Observation made on April 16, 2019, at 2:10 pm, revealed the A wing mini lounge corridor door had an unauthorized kick down hold open device installed.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the door was impeded from closing.









 Plan of Correction - To be completed: 06/12/2019

A wing room 114 and B wing room 209 doors have been fixed and now completely close and positively latch into frames.
A wing mini lounge corridor door's unauthorized kick down hold open device has been removed.
Maintenance director with audit all doors semi annually to ensure all doors completely close and positively latch.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on document review and interview, it was determined the facility failed to provide smoke compartments not greater than 22,500 square feet, with a travel distance not to exceed 200 feet, affecting one of four smoke compartments.

Findings include:

1. Observation and document review on April 16, 2019, at 11:15 am, revealed the smoke compartments in the front and back hallways exceed 200 square feet in length.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the B Wing smoke compartments exceeded 22,500 square feet..







 Plan of Correction - To be completed: 06/11/2019

Facility requests for the Department of Health to complete the FSES.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain annual inspections of fire rated door openings, affecting the entire facility.

Findings include:

1. Review of documents on April 16, 2019, between 8:30 am and 11:00 am, revealed the facility was unable to provide annual fire rated door assembly inspection and testing information.

Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the documentation was unavailable.












 Plan of Correction - To be completed: 06/11/2019

Fire rated door inspection and testing information has been scheduled with a fire protection specialist to inspect all doors.
Maintenance director or designee will ensure fire rated door assembly inspection and testing information is taking place annually. Documentation of inspection and testing information will be kept in the life safety book for review.
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 - Component: 01 - Tag: 0921

Based on documentation review and interview, it was determined the facility failed to maintain inspection of electrical receptacles, affecting all resident bed locations.
Findings include:
1. Review of documents on April 16, 2019, between 8:45 am to 11:00 am, revealed the required annual inspection of receptacles in resident 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 the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the documentation was unavailable










 Plan of Correction - To be completed: 06/05/2019

Receptacle inspection will be completed in the flowing areas...
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).
Procedure put in place for Maintenance director or designee to inspect and document annually to ensure compliance. Documentation will be kept in the life safety inspection book.



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