Nursing Investigation Results -

Pennsylvania Department of Health
PINECREST MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PINECREST MANOR
Inspection Results For:
There are 33 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.


PINECREST MANOR - 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 September 19, 2019, at Pinecrest Manor, 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 # 010902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 19, 2019, it was determined that Pinecrest Manor, 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 building, that 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 - Component: 01 - Tag: 0100

Based on document review and interview it was determined that the facility failed to test and clean carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

1. Document review on September 19, 2019, at 9:30 a.m., revealed the following carbon monoxide detector testing and inspections lacked documentation for the previous twelve months:
A. monthly test button activation;
B. annual carbon monoxide detector cleaning per manufacturer's recommendations.

Interview with the maintenance supervisor on September 19, 2019, at 9:30 a.m., confirmed the facility lacked documentation for the carbon monoxide detector testing and cleaning.

Plan of Correction - To be completed: 09/30/2019

1. All three carbon monoxide detectors will be checked and cleaned per regulation.

2. The corrective action date will be September 30, 2019.

3. The facility carbon monoxide policy was updated to include monthly testing and annual cleaning. All maintenance employees will be educated on the carbon monoxide policy.

4. Audits will be completed on testing the carbon monoxide detectors monthly and an audit will be completed on annual cleaning of the carbon monoxide detectors. These audits will be reported at the Quarterly Quality Assurance Program Committee Meeting.

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 that the facility failed to maintain hazardous areas with doors that are self closing in accordance with 7.2.1.8, on one of six wings.

Findings include:

Observation on September 19, 2019, at 12:20 p.m., revealed the F-wing, soiled utility room corridor door, failed to close and latch into the frame.

Interview with the maintenance supervisor and the interim director of nursing on September 19, 2019 at 12:20 p.m. confirmed the F-Wing soiled utility room corridor door failed to close and latch into the frame.

Plan of Correction - To be completed: 10/06/2019

1. The soiled utility room corridor door on F-wing will be fixed so that it latches positively.

2. Corrective action date will be October 6, 2019.

3. Education will be completed to employees on reporting to maintenance any doors that do not latch properly.

4. Audits will be completed monthly by the Director of Maintenance or his designee on all doors on to ensure positive latching. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

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 - Component: 01 - Tag: 0353

Based on observation and interview it was determined that the facility failed to inspect and maintain the automatic sprinkler system, on five of six wings.

Findings include:

1. Observation on September 19, 2019, between 12:25 p.m. and 1:45 p.m., revealed the following corridor linen closets had shelves installed within eighteen inches of the closet sprinkler heads:
A. (12:25 p.m.), F wing;
B. (1:05 p.m.), D wing;
C. (1:21 p.m.), C wing;
D. (1:35 p.m.), B wing;
E. (1:45 p.m.), A wing.

Interview with the maintenance supervisor and the interim director of nursing on September 19, 2019, at 1:45 p.m., confirmed the linen closets listed above had a shelf installed within eighteen inches of the sprinkler heads.

Plan of Correction - To be completed: 10/30/2019

1. The top shelf will be removed from A, B, C, D, and F wings linen closets to ensure that there is an 18" space from the sprinkler heads.

2. Corrective action date is October 30, 2019.

3. All linen closets will be marked at the 18" so that there are no items placed above this line. Education will be completed to employees on the facility's sprinkler system policy.

4. Audits will be completed monthly by the Director of Maintenance or his designee on all linen closets to ensure items are not placed 18" from the sprinkler head. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview it was determined that the facility failed to maintain smoke barriers to resist the passage of smoke, throughout the building.

Findings include:

Observation on September 19, 2019, between 11:00 a.m. and 3:00 p.m., revealed the smoke barriers throughout the building had unsealed penetrations, above the lay-in ceiling.

Interview with the maintenance supervisor, the interim director of nursing and the administrator on September 19, 2019, at 3:00 p.m., confirmed the smoke barriers throughout the building had unsealed penetrations.

Plan of Correction - To be completed: 12/30/2019

1. Facility is requesting an FSES be conducted using the 2012 Life Safety Code. Facility is currently undergoing renovations which include the completion of the smoke barriers on each neighborhood. These renovations are planned to be completed May 2021.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview it was determined that the facility failed to conduct fire drills at unexpected times, greater than one hour apart, under varying conditions, on three of three shifts.

Findings include:

1. Document review on September 19, 2019, at 9:10 a.m., revealed fire drills were conducted at the following times:
A. First shift, 13:08 hrs, 08:20 hrs, 08:40 hrs, 08:05 hrs;
B. Second shift, 15:21 hrs, 18:05 hrs, 15:41 hrs, 15:31 hrs;
C. Third shift, 05:40 hrs, 06:04 hrs, 05:31 hrs, 05:31 hrs.

Interview with the maintenance supervisor, the interim director of nursing and the administrator on September 19, 2019, at 9:10 a.m., confirmed the fire drills were not conducted at unexpected times.

Plan of Correction - To be completed: 10/10/2019

1. Fire drills will be assigned to ensure there is greater one hour apart between drills on three of three shifts.

2. Corrective action date by October 10, 2019.

3. All maintenance employees will be educated on the facility's fire drill policy.

4. Audits will be completed monthly by the Director of Maintenance or his designee on fire drills to ensure the drill is greater than one hour apart between the last drill on three of three shifts. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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 observation and interview it was determined that the facility failed to inspect and maintain fire rated doors, per NFPA 80, on one of one building separations.

Findings include:

Observation on September 19, 2019, at 1:20 p.m., revealed the fire rated cross corridor doors, seperating the Dialysis building from the Main building, had a gap greater than 1/8" on the leading edge of the doors when closed.

Interview with the maintenance supervisor on September 19, 2019, at 1:20 p.m., confirmed the fire rated cross corridor doors, seperating the Dialysis building from the Main building, had a gap greater than 1/8" on the leading edge of the doors when closed.

Plan of Correction - To be completed: 10/30/2019

1. The fire rated doors separating the Dialysis building from the main building will be repaired to ensure that there is a gap no greater than 1/8" on the leading edge of the doors when closed.

2. Corrective action date by October 30, 2019.

3. A gauge will be utilized to check all fire rated doors to ensure that the gap is no greater than 1/8" on the leading edge of the doors when closed.

4. Audits will be completed quarterly by the Director of Maintenance or his designee on all fire rated doors to ensure that there is a gap no greater than 1/8" on the leading edge of the doors when closed. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

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