Pennsylvania Department of Health
SLATE BELT HEALTH & REHABILITATION CENTER
Building Inspection Results

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SLATE BELT HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  41 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.
SLATE BELT HEALTH & 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 15, 2024, at Slate Belt Health and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID 193102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 15, 2023, it was determined that Slate Belt Health 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 three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting three of three floors.

Findings include:

1. Observation on February 15, 2024, between 10:15 a.m. and 11:15 a.m., revealed the following:

a. 10:15 a.m., the facility exceeds the maximum allowable story height for this type of construction by one story.
b. 11:15 a.m., plywood sheathing was recently installed on the exterior wall of the second and third floor dining room area.

Exit interview with the Facility Administrator and the Facilities Manager on February 15, 2024, between 12:00 p.m., and 12:15 p.m., confirmed the building construction deficiencies.




 Plan of Correction - To be completed: 03/10/2024

FSES was reviewed and revised to meet the requirements of the FSES. The plywood sheathing installed on the second and third floor dining room area is stamped that it is APA fire rated. This plywood is only temporary and will be removed prior to the completion of the restoration projected.

To monitor and maintain ongoing compliance, the NHA/designee will request an annual review of the FSES to ensure the facility remains in compliance with this building construction deficiency.
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 two hazardous area enclosures, affecting one of three floors.

Findings include:

1. Observation on February 15, 2024, between 11:12 a.m., and 11:16 a.m., revealed the following doors lacked self-closing devices:

a. 11:12 a.m., the Emergency Supply Room.
b. 11:16 a.m., the Business Office Storage Room.

Exit interview with the Facility Administrator and the Facilities Manager on February 15, 2024, between 12:00 p.m., and 12:15 p.m., confirmed the hazardous area enclosure deficiencies.



 Plan of Correction - To be completed: 03/30/2024

Self closing door closures to be installed on both emergency supply, business office storage room doors. The expected delivery time on the doors will be 3/30/24

The maintenance director will monitor each area three times a week for the next three months and the results of the audits will be submitted to facility QAPI for review and recommendations.
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 one corridor opening, affecting one of three floors.

Findings include:

1. Observation on February 15, 2024, at 10:52 a.m., revealed the Clinical Reimbursement Office door was was not smoke-tight.

Exit interview with the Facility Administrator and the Facilities Manager on February 15, 2024, between 12:00 p.m., and 12:15 p.m., confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 03/31/2024

Clinical reimbursement office 20 minute smoke door will be replaced and comply with NFPA 101 regulations. Expected date of delivery is 3/29/24.

Facility Maintenance Director will monitor 10 smoke doors per week for 3 months and the results of the audits will be forwarded to facility QAPI for review and recommendations.
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 the electrical systems in one location, affecting one of three floors.

Findings include:

1. Observation on February 15, 2024, at 10:44 a.m., revealed a surge protector, located at the first floor, fish tank area.

Exit interview with the Facility Administrator and the Facilities Manager on February 15, 2024, between 12:00 p.m., and 12:15 p.m., confirmed the electrical systems deficiency.



 Plan of Correction - To be completed: 03/10/2024

Surge protector has been removed and a quad GFCI has been installed by a certified electrician.

To monitor and maintain ongoing compliance, the Maintenance Director will monitor all surge protectors 2 times a week for 3 months and results of these audits will be forwarded to QAPI for review and recommendations.

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