Pennsylvania Department of Health
WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 36 surveys for this facility. Please select a date to view the survey results.

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WALNUT CREEK HEALTHCARE 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 July 2, 2024, at Walnut Creek Healthcare 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: REPLACEMENT FACILITY - Component: 03 - Tag: 0000

Facility ID #020602
Component 03
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 2, 2024, it was determined that Walnut Creek Healthcare 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 one-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs for three of over forty exit signs.
Findings include:
Observation on July 2, 2024, between 9:39 a.m. and 10:15 a.m., revealed the following exit sign deficiencies:
A. (9:39 a.m.) Main floor, Neighborhood One, corridor at the right turn, was missing a directional exit sign;
B. (10:15 a.m.) Main floor, Neighborhood Five, corridor near the kitchen doorway, looking to the left, had a missing exit sign.

Interview with the maintenance director on July 2, 2024, at 10:15 a.m., confirmed the exit sign deficiencies.

Plan of Correction - To be completed: 07/29/2024

The facility maintenance supervisor will ensure Exit/Directional Signage is placed within the areas identified. The facility maintenance supervisor will audit Exit/Directional Signage once every month for three months. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

NFPA 101 STANDARD Cooking Facilities:

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.

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: REPLACEMENT FACILITY - Component: 03 - Tag: 0324

Based on observation and interview, the facility failed to maintain cooking equipment in one of one kitchen.

Findings include:

Based on observation and interview on July 2, 2024, at 10:10 a.m., revealed that an interview with a kitchen staff member was unaware of the location and operation of the manual activation of the hood fire suppression.

Interview with the maintenance director on July 2, 2024, at 10:10 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 07/29/2024

The Dietary staff member had been educated on location and operation of the manual activation of the hood suppression system. The Maintenance Supervisor will educate the Dietary staff members on the location and operation of the manual activation of the hood suppression system. The Maintenance Supervisor will conduct weekly audits to ensure that the dietary staff are knowledgeable of the location and operation of the manual activation of the hood suppression system weekly for four weeks and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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: REPLACEMENT FACILITY - Component: 03 - Tag: 0353

Based on document review and interview, the facility failed to maintain the sprinkler system for one of one sprinkler system.

Findings include:

Document review on July 2, 2024, at 11:25 a.m., revealed the last four quarterly sprinkler reports noted, "sprinkler control valves in hot box are of the non-indicating type, valves should be rising stem osy valves." This deficiency was not corrected at the time of the survey.

Interview with the administrator and the maintenance director on July 2, 2024, at 11:25 a.m., confirmed the sprinkler control valve deficiency.

Plan of Correction - To be completed: 07/29/2024

The facility will replace the non-indicating control valves with indicating type control valves. The facility will have the work scheduled for the replacement with the facility vendor. Per facility vendor, local water authority would need to do a water shut off to complete the project. This will be coordinated between the vendor and the water authority which may increase the lead time of project completion. The facility maintenance supervisor will audit quarterly sprinkler reports to ensure any deficiencies identified are corrected. The Audits will be conducted once every three months for six months. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

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