Pennsylvania Department of Health
EMERALD NURSING AND REHABILITATION
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMERALD NURSING AND REHABILITATION
Inspection Results For:

There are  39 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.
EMERALD NURSING AND REHABILITATION - 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 April 2, 2024, it was determined that Emerald Nursing and Rehabilitation had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: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.
403.748(a), 416.54(a), 418.113(a), 441.184(a), 460.84(a), 482.15(a), 483.73(a), 483.475(a), 484.102(a), 485.68(a), 485.542(a), 485.625(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at 482.15 and CAHs at 485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency preparedness plan was reviewed within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on April 2, 2024, at 9:10 AM, revealed the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed since 2/24/23.

Interview with the Environmental Services Director on April 2, 2024, at 9:10 AM, confirmed the lack of documentation verifying the emergency preparedness plan had been reviewed, within the previous twelve months.


 Plan of Correction - To be completed: 05/08/2024

1. Emergency preparedness manual was updated and reviewed. Education will be provided to Director of Maintenance and Adminstrator regarding the need for the Emergency Preparedness Plan to updated as needed but no less then yearly.
2. Monthly audits by maintenance director or designee will be completed of the Emergency Preparedness Plan to assure accurate information. Audits will be submitted to QAPI for review of recommendations.

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


Facility ID #023202
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on April 2, 2024, it was determined that Emerald Nursing and Rehabilitation 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 two-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.



 Plan of Correction:


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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on April 2, 2024, at 10:30 AM, revealed an unprotected penetration on the 1st floor Soiled Utility Room wall, beneath the suspended ceiling, in the wall shared with the Linen Closet.

Interview with the Environmental Services Director on April 2, 2024, at 10:30 AM, confirmed the unprotected penetration of the hazardous area enclosure.


2. Observation on April 2, 2024, at 11:13 AM, revealed the drywall membrane, in which the lowest sprinkler head in the basement Laundry Folding Room was installed, was removed, leaving the pendant style sprinkler head suspended in a void, and negating the smoke rating of the hazardous area.

Interview with the Environmental Services Director on April 2, 2024, at 11:13 AM, confirmed the Laundry Folding Room was not smoke tight in conjunction with the sprinkler head.



 Plan of Correction - To be completed: 05/08/2024


1.The first-floor soiled utility room wall penetration beneath suspended ceiling will be patched. Drywall will be installed around sprinkler head in basement laundry folding room.
2.Facility wide audit of Sprinkler heads and utility rooms will be conducted to ensure there are no other penetrations.
3.Facility Staff will be educated on reporting issues with walls and ceiling tiles to Maintenance for repair. Maintenance Director will be educated on ensuring penetrations are addressed any time work is done on the walls/ceilings in facility.
4.NHA/Designee will conduct audit anytime work is done on walls to ensure there are no penetrations. NHA/Designee will also conduct audit annually of facility to ensure there are no penetrations. Results will be reported to QAPI for review and recommendations.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to provide documentation verifying the fire alarm system had been subjected to a functional inspection within the previous twelve months, affecting the entire component.

Findings include:

1. Observation on April 2, 2024, at 9:30 AM, revealed the facility failed to provide documentation verifying the fire alarm system had been subjected to a functional inspection since 8/23/22.

Interview with the Environmental Services Director on April 2, 2024, at 9:30 AM, confirmed the lack of documentation verifying the fire alarm system had been subjected to a functional inspection within the previous twelve months.


 Plan of Correction - To be completed: 05/08/2024

1.Deficiency cannot be retroactively corrected.
2.Alarm company was on site 4-5-24 for inspection. Copy of annual functional test was placed in Life Safety Binder.
3.Maintenance Director was educated on frequency of Alarm inspection.
4. Semi-annual audit of the Life Safety Manual will be conducted by Nursing Home Administrator and Maintenance Director to ensure that all reports have been received and filed. Audits will be reviewed by QAPI team for any issues or recommendations.

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: MAIN BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler heads to be installed per manufacturer recommendations, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on April 2, 2024, between 10:36 AM and 11:07 AM, revealed sprinkler heads with missing escutcheons, at the following locations:

a) 10:36 AM, 1st floor, Linen Room across from Resident Room 228;
b) 11:07 AM, Kitchen, closest sprinkler head to the manual pull station, for the Kitchen suppression system.

Interview with the Environmental Services Director on April 2, 2024, at 11:07 AM, confirmed the missing sprinkler head escutcheons.


2. Observation on April 2, 2024, at 11:13 AM, revealed the drywall membrane, into which the lowest sprinkler head in the basement Laundry Folding Room was installed, was removed, leaving the pendant style sprinkler head suspended in a void.

Interview with the Environmental Services Director on April 2, 2024, at 11:13 AM, confirmed the sprinkler head was not installed per manufacturer recommendations.




 Plan of Correction - To be completed: 05/08/2024


1.Deficiency cannot be retroactively corrected.
2.An audit of all sprinkler heads will be completed. Missing escutcheons on sprinkler head in kitchen closest sprinkler head to manual pull station and 1st floor linen room across from 228 will be replaced.
3.Maintenance Director was educated on need to sprinkler heads to be installed per manufacturer's recommendations.
4.Weekly audit x 4 weeks will be conducted for missing escutcheons around sprinkler heads and monthly audits will be conducted for 2 months by Maintenance Director/designee. Maintenance Director/designee will conduct audits of sprinkler heads semi-annually. Results will be reported to QAPI for review and recommendations.

NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on April 2, 2024, at 10:37 AM, revealed three unprotected penetrations of the corridor wall behind a wall-mounted kiosk, between the 1st floor Linen Room and the Nourishment Room.

Interview with the Environmental Services Director on April 2, 2024, at 10:37 AM, confirmed the unprotected penetrations of the corridor wall.


 Plan of Correction - To be completed: 05/08/2024

1. Penetrations in walls behind wall mounted Kiosk have will be patched between the 1st floor linen room and the Nourishment room.
2. Audit of facility Kiosks was conducted to ensure there were no further penetrations.
3. Maintenance Director was educated on the penetrations in walls and the need for them to be patched.
4. NHA/Designee will conduct audit anytime work is done on walls to ensure there are no penetrations. NHA/Designee will also conduct audit annually of facility to ensure there are no penetrations. Audit results will be reviewed by QAPI for any issues or 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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance, and positive latching of corridor doors, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on April 2, 2024, at 10:50 AM, revealed two unprotected penetrations of the vision panel frame, within the basement Rehab Door, where two screws were missing.

Interview with the Environmental Services Director on April 2, 2024, at 10:50 AM, confirmed the unprotected penetrations of the corridor door.


2. Observation on April 2, 2024, at 11:06 AM, revealed the basement door to the Kitchen Dish Room failed to positively latch within the door frame.

Interview with the Environmental Services Director on April 2, 2024, at 11:06 AM, confirmed the door did not latch within the frame.


 Plan of Correction - To be completed: 05/08/2024

1.Kitchen door to dish room will be repaired and door latch functions properly and screws will be replaced on therapy room door.
2.Facility wide audit of corridor doors will be conducted for positive latch and missing screws.
3.Maintenance director was educated on the need for door to positively latch and to have all hardware installed.
4.Monthly audits of facility corridor doors will be conducted by Maintenance Director or designee. Results will be reported to QAPI for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency generator had been subjected to a continuous 4-hour load exercise within the previous 36 months, affecting the entire component.

Findings include:

1. Review of documentation on April 2, 2024, at 9:16 AM, revealed the facility failed to provide documentation verifying the emergency generator had been subjected to a continuous 4-hour load exercise within the previous 36 months.

Interview with the Environmental Services Director on April 2, 2024, at 9:16 AM, confirmed the lack of documentation verifying the emergency generator had been subjected to a continuous 4-hour load exercise within the previous 36 months.




 Plan of Correction - To be completed: 05/08/2024

1.Deficient practice cannot be retroactively corrected.
2.The Four-hour generator test was completed on 4/8/2024 and placed in Life Safety Binder.
3.Maintenance Director will be educated on K 918 and the requirements regarding generator test.
4.Maintenance Director will schedule reminder in TELS yearly. Maintenance Director will audit four-hour generator test documentation to ensure compliance. Results will be reviewed by QAPI team for any issues or 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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of extension cords, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on April 2, 2024, at 11:10 AM, revealed an extension cord plugged into an outlet within the Kitchen Dietary Office, running into the interstitial space above the suspended ceiling, traversing into the Kitchen, and supplying electrical power to a camera near the Kitchen hood.

Interviw with the Environmental Services Director on April 2, 2024, at 11:10 AM, confirmed the use of an extension cord.


 Plan of Correction - To be completed: 05/08/2024


1.Facility cameras were audited for extension cords. Extension cord will be removed from camera in Kitchen. Camera will be moved to closer to another power source without any extension cords.
2.Audit of facility kitchen will be conducted to ensure there are no other improper use of extension cords.
3.Maintenance Director and Dietary Director were educated regarding the use of extension cords.
4.Monthly audit of facility for extension cords will be conducted by Maintenance Director or designee. Results will be reported to QAPI for review and recommendations.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port