Nursing Investigation Results -

Pennsylvania Department of Health
PENNWOOD NURSING AND REHABILITATION CENTER LLC
Building Inspection Results

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PENNWOOD NURSING AND REHABILITATION CENTER LLC
Inspection Results For:

There are  38 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.
PENNWOOD NURSING AND REHABILITATION CENTER LLC - 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 9, 2020, at Village of Pennwood, 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# 016002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 9, 2020, it was determined that Village at Pennwood 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 five story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131
Based on observation and interview, it was determined the facility failed to maintain two-hour occupancy separation barriers in one instance, affecting the entire facility.

Findings include:

1. Observation on January 9, 2020, at 9:43 a.m., revealed an unsealed wire penetration in the two-hour fire rated occupancy separation wall above the ceiling at the doors seperating personal care and skilled nursing on the fifth floor.

Interview with the Facility Administrator and Maintenance Director on January 9,2020, at 2:00 p.m., confirmed the occupancy separation barrier deficiency.



 Plan of Correction - To be completed: 02/23/2020

Wire penetration in the two-hour fire rated occupancy separation wall above the ceiling at the doors separating personal care and skilled nursing on the fifth floor will be repaired to be in compliance using a UL design through penetration stop system / fire barrier sealant.

The Maintenance Department has been re- educated on NFPA 101 fire safety code in regards to penetrations.

Maintenance will inspect the fifth floor and repair any penetrations.


NFPA 101 STANDARD Building Construction Type and Height: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.
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 that the facility failed to maintain building construction fire-resistance requirements in five instances, affecting the entire facility.

Findings include:

1. Observation on January 9, 2020, at 10:30 a.m., revealed multiple unsealed penetrations in the floor and decking, inside the radiator control closet pipe chase, on all five floors.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the penetration deficiencies.


 Plan of Correction - To be completed: 02/23/2020

Penetrations in the floor and decking, inside the radiator control closet pipe chase, on all five floors will be repaired to be in compliance.

Maintenance will inspect the radiator control closets and repair any penetrations using a UL design through penetration stop system / fire barrier sealant..

The Maintenance Department has been re- educated on NFPA 101 fire safety code in regards to penetrations.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosure in six instances, affecting 9 of 10 smoke compartments.

Findings include:

1. Observation on January 9, 2020, revealed the following vertical opening enclosure deficiencies:

a) 10:05 a.m., there was a penetration in the elevator shaft above the ceiling at the elevator doors leading into number 8 elevator, on the third floor;
b) 10:38 a.m., there was a penetration in the elevator shaft above the ceiling at the elevator doors leading into number 8 elevator, on the second floor;
c) 10:45 a.m., there were penetrations sealed with non-rated materials and additional multiple unsealed holes and penetrations in the stairway shaft above the ceiling in the third floor north stairway;
d) 11:05 a.m., there were multiple unsealed holes and penetrations in the stairway shaft above the ceiling in the second floor north stairway;
e) 11:09 a.m., there was a sprinkler pipe penetration in the stairway shaft above the ceiling in the first floor south stairway on the physical therapy side;
f) 11:23 a.m., there was a large sprinkler pipe penetration in the stairway shaft above the ceiling at the door leading into the north stair tower, on the first floor.

Interview with the Facility Director and Maintenance Director on January 9, 2020, at 2:00 p.m. confirmed the vertical opening enclosure deficiencies.





 Plan of Correction - To be completed: 02/23/2020

Penetration in the elevator shaft above the ceiling at the elevator doors leading into number 8 elevator, on the third floor; Penetration in the elevator shaft above the ceiling at the elevator doors
leading into number 8 elevator, on the second floor; Penetrations sealed with non-rated materials and additional multiple unsealed holes and penetrations in the stairway shaft above the ceiling in the third floor north stairway; the multiple unsealed holes and penetrations in the stairway shaft above the ceiling in the second floor north stairway; the sprinkler pipe penetration in the stairway shaft above the ceiling in the first floor south stairway on the physical therapy side; the large sprinkler pipe
Penetration in the stairway shaft above the ceiling at the door leading into the north stair tower, on the first floor will be repaired to be in compliance using a UL design through penetration stop system / fire barrier sealant.

The Maintenance Department has been re- educated on NFPA 101 fire safety code in regards to penetrations.

Maintenance will inspect all areas for penetrations and repair any as needed.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain the kitchen hood in three instances, affecting one of 10 smoke compartments.

Findings include:

1. Observation on January 9, 2020, revealed the following cooking facility deficiencies:

a) 9:35 a.m., the kitchen hood was missing the grease catch trays on the lower left and right sides;
b) 9:37 a.m., there was a damaged filter in the kitchen hood;
c) 9:39 a.m., the kitchen suppression system pull station is mounted above the required 42 to 48 inches.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the cooking facility deficiencies.




 Plan of Correction - To be completed: 01/15/2020

The kitchen hood missing the grease catch trays on the lower left and right sides; will have the trays replaced. The damaged filter in the kitchen hood will be replaced and the kitchen suppression system pull station mounted above the required 42 to 48 inches will be remounted to be in compliance.

Maintenance and or designee will inspect the kitchen hood weekly to assure compliance.

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 documentation review, observation and interview, it was determined the facility failed to maintain the automatic sprinkler and standpipe system in nine instances, affecting the entire facility.

Findings include:

1. Documentation review on January 9, 2020, at 9:00 a.m., revealed the facility lacked documentation showing the completion of the annual maintenance and the five year flow testing of the standpipe system.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.


2. Observation on January 9, 2020, revealed the following automatic sprinkler system deficiencies:

a) 9:35 a.m., there was a dirty sprinkler head above the ice tea dispenser in the kitchen;
b) 9:45 a.m., there was a missing sprinkler escutcheon outside the the personal care separation on the kitchen side on the fifth floor;
c) 9:57 a.m., there were two missing ceiling tiles in room 422 on the fourth floor;
d) 10:15 a.m., there was a corroded sprinkler head that was also missing an escutcheon plate in the bathing room on the fourth floor (next to room 412);
e) 10:18 a.m., there was a four foot square section of the ceiling missing in the rear of the storage room on the third floor;
f) 10:50 a.m., there was a corroded sprinkler head that was also missing an escutcheon plate in the housekeeping closet on the second floor (next to room 201);
g) 11:30 a.m., there was an unsealed drop ceiling penetration in the alcove outside of the therapy department on the first floor.
h) 11:40 a.m., there was a standpipe hose connection, obstructed by an alcohol-based hand rub dispenser, by the reception desk in the first floor lobby.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.








 Plan of Correction - To be completed: 01/16/2020

Documentation showing the completion of the annual maintenance and the five year flow testing of the standpipe system will be provided upon completion.

Maintenance will monitor to assure compliance.

The dirty sprinkler head above the ice tea dispenser in the kitchen has been cleaned.

Maintenance and or designee will monitor weekly for compliance.

The missing sprinkler escutcheon outside the personal care separation on the kitchen side on the fifth floor has been replaced.

Maintenance will monitor weekly for compliance.

The two missing ceiling tiles in room 422 on the fourth floor have been replaced.
Maintenance will monitor weekly for compliance.

The corroded sprinkler head that was also missing an escutcheon plate in the bathing room on the fourth floor (next to room 412) have been replaced.

Maintenance will monitor weekly for compliance.

The four foot square section of the ceiling missing in the rear of the storage room
on the third floor has been replaced.

Maintenance will monitor weekly to assure compliance.

The corroded sprinkler head that was also missing an escutcheon plate in the housekeeping closet on the second floor (next to room 201) have both been replaced.

Maintenance will monitor weekly to assure compliance.

The unsealed drop ceiling penetration in the alcove outside of the therapy department on the first floor has been repaired by maintenance.

The Maintenance Department has been re- educated on NFPA 101 fire safety code in regards to penetrations.

Maintenance will monitor weekly for compliance.

The standpipe hose connection, obstructed by an alcohol-based hand rub dispenser, by the reception desk in the first floor lobby has been removed to not obstruct the stand pipe.

Maintenance will monitor weekly for compliance.


NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishing equipment in one instance, affecting one out of ten smoke compartments.

Findings include:

1. Observation on January 9, 2020, at 9:42 a.m., revealed a fire extinguisher that was obstructed by a food prep table in the kitchen.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the fire extinguisher deficiency.



 Plan of Correction - To be completed: 01/10/2020

The fire extinguisher that was obstructed by a food prep table in the kitchen has been cleared from being obstructed.

Maintenance and or designee will monitor weekly for compliance.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined that the facility failed to maintain corridor doors in one instance, affecting one out of ten smoke compartments.

Findings include:

1. Observation on January 9, 2020, revealed the corridor door for room 217 on the second floor failed to latch in its frame when tested.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the corridor door deficiency.





 Plan of Correction - To be completed: 02/23/2020

The corridor door for room 217 on the second floor that failed to latch in its frame when tested has been fixed to latch properly in its frame.

Maintenance will monitor weekly for compliance.

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 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of ten smoke compartments.

Findings include:

1. Observation on January 9, 2020, at 10:17 a.m., revealed an unsealed data wire penetration above the smoke barrier doors on the third floor.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the unsealed penetration.




 Plan of Correction - To be completed: 02/23/2020

The unsealed data wire penetration above the smoke barrier doors on the third floor has been sealed using a UL design through penetration stop system / fire barrier sealant.

Maintenance will monitor for compliance.

NFPA 101 STANDARD Electrical Systems - Receptacles: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.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined that the facility failed to maintain electrical receptacles in two instances, affecting two out of over two hundred receptacles inspected.

Findings include:

1. Observation on January 9, 2020, at 11:45 a.m., revealed two outlets, that were not GFCI protected, within six foot of a sink, in the first floor hair salon.

Interview with the Facility Administrator and Maintenance Director on January 9, 2020, at 2:00 p.m., confirmed the electrical receptacle deficiencies.



 Plan of Correction - To be completed: 01/10/2020

The two outlets, that were not GFCI protected, within six foot of a sink, in the first floor hair salon have been replaced.

Maintenance will monitor to remain in compliance


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