Nursing Investigation Results -

Pennsylvania Department of Health
EDISON MANOR NURSING & REHAB CENTER
Building Inspection Results

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EDISON MANOR NURSING & REHAB CENTER
Inspection Results For:

There are  28 surveys for this facility. Please select a date to view the survey results.

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EDISON MANOR NURSING & REHAB 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 September 17, 2019 at Edison Manor Nursing and Rehab 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 01 - Component: 01 - Tag: 0000


Facility ID # 025902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 17, 2019, it was determined that Edison Manor Nursing and Rehab 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 three-story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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 on all building levels.

Findings include:

Observation on September 17, 2019, at 8:00 a.m., revealed the facility exceeds the height requirements for this type of construction: three-story, Type II (000), unprotected, noncombustible building.

Interview with the maintenance supervisor on September 17, 2019, at 8:00 a.m., confirmed the building exceeds the height requirement for this type of construction type.




 Plan of Correction - To be completed: 10/17/2019

This plan of correction is prepared because it is required by State and Federal law and not because Edison Manor Nursing and Rehabilitation Center agrees with the allegations and citations listed on pages 1-8 of this statement of deficiencies (SOD). Edison Manor Nursing and Rehabilitation Center does not admit any deficiency is present. Edison Manor Nursing and Rehabilitation Center is constantly reviewing and revising its policies, procedures, and methods of health care service delivery. There are no subsequent remedial measures undertaken in response to the SOD and no admission can be inferred from Edison Manor Nursing and Rehabilitation Center continuing the process of enhancing the facility's practices. This plan of correction shall operate as Edison Manor Nursing and Rehabilitation Center's written credible allegation of compliance effective October 17, 2019.


K 0161

No adverse affects occurred from the facility exceeding the height requirement for this construction type.

Life Safety Consultant Peters Rice Associates conducted an FSES on 3/20/2017, which is on file with the Department of Health.


Edison Manor has been working with various vendors on a construction proposal that will minimize disturbance to the residents of the facility. Once a viable proposal has been acquired the facility will submit architectural plans and determine the time frame to have the work completed to stay in compliance with our 5 year waiver.


Edison would like to ask for a continuation of the 5 year time limited waiver.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 01 - Component: 01 - Tag: 0345

Based on document review and interview it was determined that the facility failed to maintain the fire alarm and smoke detection system, on one of three levels.

Findings include:

Document review on September 17, 2019, at 8:30 a.m., revealed the fire alarm sensitivity test report dated September 16, 2019, indicated one smoke detector failed the sensitivity test.

Interview with the maintenance supervisor on September 17, 2019, at 8:30 a.m., confirmed the fire alarm sensitivity test report dated September 16, 2019, indicated one smoke detector failed the sensitivity test.




 Plan of Correction - To be completed: 10/17/2019

K 0345

No adverse affects occurred from the one smoke detector failing the sensitivity test on September 16, 2019.

Maintenance Director will be educated on maintaining additional smoke detectors one for each type of detector we have in house. The work has been scheduled through our vendor to be completed.

The Administrator or designee will be responsible for ensuring replacement of the failed smoke detector.

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 01 - Component: 01 - Tag: 0741

Based on observation and interview it was determined that the facility failed to provide a metal, self closing, self extinguishing container, to empty ashtrays into, in one of two smoking areas.

Findings include:

Observation on September 17, 2019, at 11:55 a.m., revealed the designated employee smoking area lacked a metal, self closing, self extinguishing container, to empty smoking materials into prior to disposal.

Interview with the maintenance supervisor and the administrator on September 17, 2019, at 11:55 a.m., confirmed the designated employee smoking area lacked a metal, self closing, self extinguishing container, to empty smoking materials into prior to disposal.





 Plan of Correction - To be completed: 10/17/2019

K 0741

No adverse affects occurred from the employee designated smoking area lacking a metal, self-closing, self-extinguishing container to empty smoking material in prior to disposal.

Edison Manor will provide education to the Maintenance supervisor, the facility has purchased the proper metal, self-closing, self-extinguishing container.

The Administrator or designee will be responsible for ongoing compliance to ensure safe disposal of cigarette butts. Audits will be completed 5 times a week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 01 - Component: 01 - Tag: 0918

Based on observation and interview it was determined that the facility failed to install an emergency generator emergency shut off switch located outside the emergency generator room, on one of one emergency generators, per NFPA 110-5.6.5.6.

Findings include:

Observation on September 17, 2019, at 12:20 p.m., revealed the emergency generator, located on the first floor, lacked an emergency shut off switch that was located outside the emergency generator room.

Interview with the maintenance supervisor and administrator on September 17, 2019, at 12:20 p.m., confirmed the emergency generator lacked a remote shut off switch located outside the emergency generator room.




 Plan of Correction - To be completed: 10/17/2019


K 0918

No adverse affects occurred from the lack of an emergency shut off switch that was located on the outside of the generator room.

Penn Power Systems has been contacted and will perform the installation of the shut off switch.

The Administrator or designee will be responsible for ensuring placement of generator shut off switch is completed.


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