Nursing Investigation Results -

Pennsylvania Department of Health
GINO J. MERLI VETERANS CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GINO J. MERLI VETERANS CENTER
Inspection Results For:

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GINO J. MERLI VETERANS 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 January 22-23, 2020, at Gino J. Merli Veterans 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 - Component: 01 - Tag: 0000


Facility ID #014902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 22-23, 2020, it was determined that Gino J. Merli Veterans 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 483.70(a).

This is a three story, Type II (222) fire resistive structure, with a basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain exit stair towers, affecting one of eight exit stairs.

Findings include:

1. Observation on January 22, 2020, revealed the third floor, "F" Stair Tower was unprotected when viewed from the corridor side.

Exit interview with the facility assistant administrator and facility representative #1, on January 23, 2020, at 11:00 a.m., confirmed the unprotected stair riser.





 Plan of Correction - To be completed: 02/24/2020

Unprotected stair riser in stairwell Tower F has been filled with fire safing and fire caulk and is now in compliance.
Stairwells will be inspected for unprotected areas and brought into compliance.
Semi-annual inspections of stairwells throughout the facility will be conducted to detect and repair any unprotected areas in stairwells.
Completion date is February 24, 2020.

NFPA 101 STANDARD Discharge from Exits: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.
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 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain exit discharges, affecting one of eighteen smoke compartments.

Findings include:

1. Observation on January 22, 2020, at 10:35 a.m., revealed the exit discharge located outside the "A" Stair Tower was not cleared of snow and ice.

Exit interview with the facility assistant administrator and facility representative #1, on January 23, 2020, at 11:00 a.m., confirmed the exit discharge.




 Plan of Correction - To be completed: 02/24/2020

Exit discharge located outside the A stair tower was immediately cleared of ice and snow.
Other exits have been inspected and found to be clear of ice and snow.
When snowfall and ice occur, exits will be inspected and snow and ice removed, along with ice melt applied.
Completion date is February 24, 2020.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors, affecting one of eighteen smoke compartments.

Findings include:

1. Observation on January 22, 2020, at 10:10 a.m., revealed the 3rd floor corridor door #318 could not close and latch.

Exit interview with the facility assistant administrator and facility representative #1, on January 23, 2020, at 11:00 a.m., confirmed the corridor door.




 Plan of Correction - To be completed: 02/24/2020

Room 318 door was immediately adjusted to insure proper closure. Resident room doors were inspected and adjusted.
Random audits of resident room door closure will be conducted on 5 doors on each nursing unit weekly for 8 weeks.
Corridor doors are inspected semi-annually for proper closure. Any doors found to be not closing properly are adjusted or replaced.
Completion date is February 24, 2020.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one-half hour fire resistance rating, affecting two of eighteen smoke compartments.

Findings include:

1. Observation on January 23, 2020, at 9:15 a.m., revealed unsealed penetrations around communication wires located in the 2nd floor Multi-Purpose room.

Exit interview with the facility assistant administrator and facility representative #1, on January 23, 2020, at 11:00 a.m., confirmed the penetrations.




 Plan of Correction - To be completed: 02/24/2020

Penetrations found around communication wires in Multi Purpose Room were immediately sealed.
Audits will be conducted of 5 random areas in the basement, 5 random areas on the first floor, 5 random areas on the second floor and 5 random areas on the third floor to locate and repair any penetrations for 6 weeks.
Semi-annual inspections of 10 random areas on each floor will be conducted in addition to semi-annual inspection of smoke walls.
Completion date is February 24, 2020.

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas in one instance outside this component.

Findings include:

1. Observation on January 22, 2020, at 12:10 p.m., revealed a staff employee smoking outside the "G" Stair Tower door. The facility has a No Smoking Policy.

Exit interview with the facility assistant administrator and facility representative #1, on January 23, 2020, at 11:00 a.m., confirmed the employee smoking.




 Plan of Correction - To be completed: 02/24/2020

Due process conference was conducted with employee for smoking on premises. No Smoking signs will be posted at all fire exits.
While conducting daily rounds of exterior of the facility, Security will check on day, evening and night shift to ensure staff is in compliance with the smoking policy.
Random video checks of the fire exits will be conducted weekly by Security for 8 weeks.
Completion date is February 24, 2020.


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