Nursing Investigation Results -

Pennsylvania Department of Health
CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER
Inspection Results For:

There are  28 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.
CHESTNUT HILL LODGE HEALTH 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 February 21, 2019, it was determined that Chestnut Hill Lodge Health 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(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include a plan to ensure the emergency generator remain operational during an emergency, affecting the entire facility.

Findings include:

1. Document review on February 21, 2019, at 8:00 am, revealed the facility's Emergency Preparedness Plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event the primary fuel supplier is unavailable during an emergency.

Interview at the exit conference with the Administrator, on February 21, 2019, at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure facility develops an Emergency Preparedness Plan that ensures the emergency generator remain operational during an emergency. Facility has obtained a secondary generator fuel supplier for the emergency generator. The Emergency Preparedness plan has been updated to include a written plan and agreement with a secondary fuel supplier.
Initial comments:Name: MAIN BUILDING 01 (A, B, C, D, WINGS) - Component: 01 - Tag: 0000


Facility ID# 700102
Component 01
A, B, C and D Wings

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2019, it was determined that Chestnut Hill Lodge Health and Rehabilitation Center (A, B, C and D Wings) 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 construction, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 (A, B, C, D, WINGS) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility.

Findings Include:

1. Document review on February 21, 2019, at 8:00 am, revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed accurate portable floor plans were not available.



 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure accurate floor plans are available. Facility floor plans have been updated to include the following: Smoke Barrier Walls (outside wall to outside wall), Fire Barrier Walls (2-hour walls), Horizontal Exits, Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms), Required Exits (clearly noted) and Shaft Walls. The maintenance director will ensure the proper plans are updated and kept in a secured location in the facility.
NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 (A, B, C, D, WINGS) - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain the installation of smoke detectors, affecting 1 of 8 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019, at 12:56 pm, 1st floor B-wing, revealed in the short corridor near the HR payroll office there was a gap around a pipe penetrating a suspended ceiling tile, which could delay activation of the smoke detector.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the gap near a smoke detector.


2. Observation made on February 21, 2019, at 1:12 pm, 1st floor B-wing, revealed in the corridor near resident room number B25, there was smoke detector dislodged from the ceiling.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019, at 2:50 pm, confirmed there was a smoke detector dislodged from the ceiling.




 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure it maintains the installation of smoke detectors throughout all smoke zones. In regards to the gap around the pip near the HR office, the gap will be closed and sealed if necessary to ensure a delay will not occur during smoke detector activation. In regards to the smoke detector dislodged from the ceiling tile in front of B25, the smoke detector will be rehung and installed properly to ensure it is properly placed and operates properly. The maintenance department will monthly audit for penetrations throughout the facility while doing rounds with corrective measures as needed. Findings will be reported to the safety committee. An education will be provided to all maintenance staff on looking for penetrations and how to action them. Maintenance will be educated about the importance of having fire detectors and other ceiling and wall fixtures secured and in proper working condition. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 (A, B, C, D, WINGS) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure that automatic sprinkler system components were protected, maintained within a smoke tight assembly, and were free of obstructions, affecting the entire component.

Findings include:

1. Observation made on February 21, 2019, at 11:23 am, revealed in the parking lot area, the two sets of double doors to the sprinkler pit were unlocked, had broken hinges and had rusted door frame stops, resulting in the doors starting to cave into the pit.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the sprinkler pit door deficiencies listed above.


2. Observation made on February 21, 2019, at 1:04 pm, 1st floor B-wing short corridor, revealed inside the personal laundry room, the top of a stacked washer/dryer unit was less than 18 inches from a sprinkler.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the washer/dryer unit was less than 18 inches from the sprinkler.


3. Observation made on February 21, 2019, at 2:00 pm, 1st floor main entrance lobby, revealed a sprinkler missing an escutcheon.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed a sprinkler was missing an escutcheon.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure that automatic sprinkler system components are protected, maintained within a smoke tight assembly and were free of obstruction, affecting the entire component. In reference to #1. The double doors to the sprinkler pits near the parking lot area had new locking hasp clasp locks installed on them and secured with a pad lock. The door frames will be reinforced to ensure they are secured. Maintenance maintains the keys and an emergency key is kept with on the 24hr Nursing supervisor key ring. In reference to #2.the stacked washer/dryer on B-Wing, a space from the top of the washer/dryer unit to the sprinkler head will be at a distance of at least 18 inches. In reference to #3. the sprinkler missing an escutcheon in the first floor lobby, an escutcheon will be installed to ensure there are no spaces between the sprinkler head and ceiling tile. Maintenance director will educate staff on the importance of no objects within 18 inches of ceiling. The maintenance department monthly will audit for and replace missing escutcheons and monitor 18" clearance with corrective measures as needed throughout the facility while doing rounds. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits. Maintenance will also be re-educated to look for all sprinkler head escutcheons throughout the facility.
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 (A, B, C, D, WINGS) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were smoke tight when closed, affecting 1 of 8 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019, at 12:18 pm, 1st floor A-wing, revealed the door to resident room number A12 had a gap greater than a half-inch, which would not resist the passage of smoke.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019, at 2:50 pm, confirmed the door had a gap.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure corridor doors are smoke tight when closed throughout all smoke zones. In regards to the door that leads into resident room number A12, the door will be adjusted to ensure that the gap is no greater than a half an inch to ensure it would resist the passage of smoke. Maintenance director will complete audits monthly on resident's doors to ensure the proper closure gap of an half of inch or less is properly maintained. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
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 (A, B, C, D, WINGS) - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure smoke barrier doors resisted the passage of smoke, affecting 4 of 8 smoke zones within the component.

Findings include:

1. Observations made on February 21, 2019, between 11:30 am and 1:07 pm, revealed smoke barrier doors that failed to close to resist the passage of smoke in the following locations:

a. 11:30 am, 1st floor, the smoke barrier double doors located next to the social services office;
b. 1:07 pm, 1st floor B-wing, the smoke barrier double doors near resident room B15.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the doors would not fully close in the above named locations.




 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure smoke barrier doors will resist the passage of smoke throughout all smoke zones. In regards to the smoke barrier double doors that failed to close in front of social service office, the doors were tested to ensure they close properly to resist the passage of smoke. In regards to the smoke barrier double doors in front of room B15, the doors were tested to ensure they close properly to resist the passage of smoke. The maintenance director will be re-educated on how to properly test the fire alarm system. Audits will be completed monthly to ensure all smoke barrier doors close properly to resist the passage of smoke. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
NFPA 101 STANDARD HVAC - Any Heating Device: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.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: MAIN BUILDING 01 (A, B, C, D, WINGS) - Component: 01 - Tag: 0522

Based on observation and interview, it was determined the facility failed to maintain heating units free of combustible materials, affecting 1 of 8 smoke zones within the facility.

Findings include:

1. Observation made on February 21, 2019, at 12:22 pm, 1st floor, revealed clothing was placed on a heater unit inside resident room A7.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed there was clothing placed on a heater unit.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure that all heating units are free of combustible materials throughout all smoke zones within the facility. In regards to the clothing placed on a heater in resident room A7, the clothing was removed and resident was educated on the importance of not placing combustible materials on a heating source. Nurses as well as CNA's will be re-educated that while doing rounds and providing care to look out for any combustible items that could be on or directly surrounding a heating source. To audit this, a new line will be added to the safety audit that is performed monthly. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
NFPA 101 STANDARD Portable Space Heaters: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.
Portable Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8
Observations:
Name: MAIN BUILDING 01 (A, B, C, D, WINGS) - Component: 01 - Tag: 0781

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of portable space, affecting 1 of 8 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019, at 12:52 pm, 1st floor B-wing, revealed a portable electric space heater was in use inside the business office. Verification the heating element did not exceed 212 degrees Fahrenheit was not available.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed a portable electric space heater was in use.







 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure that we prohibit the use of unauthorized portable space heaters. In regards to the portable heater located in the business office, the portable heater has been removed from the office and properly disposed of since there was no verification of the heating element if it exceeded 212 degrees or not. All administrative staff was re-educated that unauthorized portable space heaters are not to be used inside the facility. An audit will be conducted monthly to ensure there are no unauthorized space heaters being used in the facility. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
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 (A, B, C, D, WINGS) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to unauthorized use of electrical devices, affecting 2 of 8 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019, at 12:55 pm, 1st floor, revealed inside the business office, there was a refrigerator and a microwave oven plugged into two powerstrips. In addition, both of the powerstips were plugged into a 4-outlet multiplier.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the improper use of powerstrips and the prohibited use of outlet multipliers.


2. Observation made on February 21, 2019, at 1:20 pm, B-wing basement, revealed inside the main laundry room, above the door to the elevator machine room, there was an extension cord run across the suspended ceiling.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the prohibited use of an extension cord.






 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure there is no unauthorized use of electrical devices throughout all smoke zones in the facility. In regards to #1. the microwave and refrigerator in the business office plugged into two power strips and that both power strips were plugged into a 4-outlet multiplier, the refrigerator and microwave were both unplugged from power strips and moved to a location in the business office where the both can be plugged into a single outlet directly into the wall. The power strips and multiplier were unplugged and removed. In regards to #2. the extension cord in the laundry room that ran across the suspended ceiling, that cord has been unplugged and stored away. All administration has been re-educated on how to properly use of electrical devices in the facility. Maintenance staff will complete an audit monthly in the facility to look for improper uses of electrical devices, power strips and multipliers. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
Initial comments:Name: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0000


Facility ID# 700102
Component 02
A/E and E Wings

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2019, it was determined that Chestnut Hill Lodge Health and Rehabilitation Center (A/E and E Wings) 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 II (000), unprotected non-combustible construction, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Egress 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.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0222

Based on observation and interview, it was determined the facility failed to ensure egress doors with delayed-egress locking systems had required signage displayed, affecting 1 of 2 levels within the component.
Findings include:

1. Observations made on February 21, 2019, between 11:50 am and 12:00 pm, revealed egress doors with delayed-egress locking systems installed that lacked required signage, in the following locations:

"PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS "

a. 11:50 am, 1st floor, the stair tower door next to the living room area;
b. 12:00 pm, 1st floor, the stair tower door near resident room # E118.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the doors lacked the delayed egress signage in the above named locations.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure egress doors with delayed egress locking systems have required signage displayed. Facility ordered and will place required signage on 1st floor tower door by living and area and 1st floor tower door by room E118. Maintenance inspected all delayed egress locking systems to ensure required signage.
NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0223

Based on observation and interview, it was determined the facility failed to ensure the fire alarm automatically activates required control functions, affecting 2 of 3 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019, at 11:45 am, basement, revealed the door to the employee break room that is located in an exit passageway failed to positively latch when tested.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the door failed to latch.


2. Observations made on February 21, 2019, between 2:09 pm and 2:14 pm, revealed magnetically held open rated doors that failed to release upon activation of the fire alarm in the following locations:

a. 2:09 pm, 1st floor E-wing double doors near resident room number 107.
b. 2:14 pm, 1st floor A/E-wing double doors near resident room number 102.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the doors failed to release upon activation of the fire alarm in the above named locations.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure the fire alarm automatically activates required control functions for smoke zones. Employee break room door latch was adjusted to ensure positive latching. The smoke barrier double doors near room E107 & A/E 102, were tested to ensure they close properly to resist the passage of smoke. The maintenance director will be re-educated on how to properly test the fire alarm system. All smoke zone doors will be audited monthly with corrective measures as needed. to ensure all smoke barrier doors close properly to resist the passage of smoke. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0353


Based on observation and interview, it was determined the facility failed to ensure that automatic sprinkler system components were maintained and protected, affecting the entire component.

Findings include:

1. Observation made on February 21, 2019, at 11:23 am, revealed in the parking lot area, the two sets of double doors to the sprinkler pit were unlocked, had broken hinges and had rusted door frame stops resulting in the doors starting to cave into the pit.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the sprinkler pit door deficiencies listed above.


2. Observation made on February 21, 2019, at 11:51 am, 1st floor, revealed in the corridor near the double doors to the living room area, there was a sprinkler missing an escutcheon.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the sprinkler was missing an escutcheon.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure that automatic sprinkler system components are protected, maintained within a smoke tight assembly and were free of obstruction, affecting the entire component. In regards to #1.the double doors to the sprinkler pits near the parking lot area, the doors had new locking hasp clasp locks installed on them and secured with a pad lock. The door frames will be reinforced so ensure they are secured. The keys are maintained by the Maintenance Director and a backup is on the 24hr Supervisor keys. In regard to #2.the sprinkler missing an escutcheon in the first floor living area near the double doors, an escutcheon will be installed to ensure there are no spaces between the sprinkler head and ceiling tile. Maintenance director will educate staff on the importance of securing entranceways that lead to subsurface areas and to ensure all sprinkler head escutcheons throughout the facility are in place. The maintenance department will audit monthly for and replace missing escutcheons as needed throughout the facility while doing rounds. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
NFPA 101 STANDARD Electrical Systems - Other: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 - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring affecting 1 of 3 smoke zones within the component. Installation shall be in accordance with NFPA 99 Section 6.3.2.1.

Findings include:

1. Observation made on February 21, 2019 at 11:30 am, basement, revealed inside the basement storage room located next to the maintenance office, there was a ceiling mounted light fixture hanging by it's wiring.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the light fixture was hanging by it's wiring.




 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to maintain electrical wiring affecting smoke zones. The mounted light fixture in the storage room next to the maintenance office was secured. Maintenance was educated of importance of ensuring ceiling fixtures are properly secured. Maintenance will audit ceiling fixtures monthly with corrective action as needed. Findings will be reported to the safety committee. Safety committee findings will be reviewed/reported to QAPI committee to determine trends, compliance. QAPI committee will determine need for audits.
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: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0920

Based on observation and interview it was determined the facility failed to ensure that the improper use of power strips is prohibited, affecting 1 of 3 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019 at 12:05 pm, 1st floor, revealed there was a refrigerator plugged into a powerstrip inside resident room number E99.

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed a refrigerator plugged into a powerstrip.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure there is no unauthorized use of electrical devices throughout all smoke zones in the facility. The refrigerator was unplugged from the power strip in room E99 and plugged appropriately into wall outlet. All administration has been re-educated on how to properly use of electrical devices in the facility. Maintenance staff will complete an audit monthly in the facility to look for proper uses of electrical devices. Findings will be reported to the safety committee. Safety committee
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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: BUILDING 02 (A/E AND E WINGS) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure required medical gas signage was present, affecting 1 of 3 smoke zones within the component.

Findings include:

1. Observation made on February 21, 2019 at 12:07 pm, 1st floor, revealed that the door to the portable oxygen cylinder storage closet that is across from resident room number E100 did not have the following signage that states:

"CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Interview at the exit conference with the Administrator and the Corporate Building Manager, on February 21, 2019 at 2:50 pm, confirmed the door lacked the required signage.





 Plan of Correction - To be completed: 04/15/2019

The provider submits the following plan of correction in good faith and comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the Statement of deficiencies. It is the practice of this facility to ensure required medical gas signage is present. Facility ordered and will place required medical gas signage on the portable oxygen cylinder storage closet across from room E100. Maintenance inspected all oxygen cylinder storage closets to ensure required signage.

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