Pennsylvania Department of Health
KINGSTON COURT SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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KINGSTON COURT SKILLED NURSING 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 August 5, 2024, at Kingston Court Skilled Nursing 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: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #026302
Building 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 5, 2024, it was determined that Kingston Court Skilled Nursing 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 (000), unprotected wood frame structure, with a partial mechanical basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on August 5, 2024, between 8:00 AM and 10:30 AM, revealed the facility lacked resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the facility floor plans lacked information requried to complete a survey.

Plan of Correction - To be completed: 09/24/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

A new floor plan will be created for the facility to include resident room capacity, fire wall boundaries, smoke wall boundaries and hazardous areas

Floor plan was observed / checked to include all necessary information

Audit to be completed quarterly to ensure compliance of floor plan and ensure floor plans are filed correctly

Audit / trends will be reviewed monthly by the safety committee for further recommendations.

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit doors to be free of impediments to opening, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on August 5, 2024, at 12:25 PM, revealed Heritage Short Hall exit discharge door required a force, of more than 30 pounds, to set the doors in motion.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the door failed to open without excessive force.

Plan of Correction - To be completed: 09/24/2024

The Heritage short hall exit door will be adjusted to require a force of less than 30 pounds to set the doors in motion

Rated doors in the cited area have been observed / checked for proper opening force ratings

Audit of random exit doors will be completed weekly for 4 weeks to ensure compliance and then monthly thereafter

Audit / trends will be reviewed monthly by the safety committee for further recommendations

NFPA 101 STANDARD Cooking Facilities:

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 - Component: 01 - Tag: 0324
Based on document review and interview, it was determined the facility failed to conduct monthly owner's quick check on the building's Kitchen Suppression System, affecting one of four smoke compartments within the component.

Findings include:

1. Review of documentation on August 5, 2024, between 8:00 AM and 10:30 AM, revealed the facility lacked documentation of monthly "quick checks" being performed, on the Kitchen Suppression System.

Interview with the Administrator, Environmental Services Manager and York South Mainteneace Director on August 5, 2024, at 1:30 PM, confirmed the facility could not provide documentation of the monthly owner's quick checks.

Plan of Correction - To be completed: 09/24/2024

Monthly owners "quick check" inspection will be performed

"Quick check" inspections will include obstruction, tamper seals, blowoff caps and physical damage

An audit of "quick check" inspections will be completed weekly for 4 weeks to ensure compliance. An audit will be conducted every 3 months to ensure that tests are performed, documented and filed in the life safety book

Audit / trends will be reviewed monthly by the safety committee for further recommendations

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 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide quarterly and semiannual sprinkler maintenance documentation and failed to maintain the automatic sprinkler system, to be free of obstructions, affecting the entire component.

Findings include:

1. Review of documentation on August 5, 2024, between 8:00 AM and 10:30 AM, revealed the facility lacked documentation, for the following:

a. 9:10 AM, 4th quarter wet and dry quarterly inspection;
b. 9:12 AM, semi-annual supervisory switches;
c. 9:13 AM, semi-annual waterflow alarm devices.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the lack of installed sprinkler documentation.

2. Observation on August 5, 2024, between 11:15 AM and 11:25 AM, revealed sprinkler heads had a high load of dust, at the following locations:

a. 11:15 AM, Laundry, Clean Linen Area, 2 heads;
b. 11:15 AM, Laundry, Dryer Chase, 2 heads;
c. 11:25 AM, Laboratory, Main Entrance Hall, right side, 1 head.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the sprinkler heads carried a high load of dust.

Plan of Correction - To be completed: 09/24/2024

The debris was removed from sprinkler heads in the laundry area. The quarterly inspections will be performed on a regular basis

The sprinkler heads have been observed / checked to ensure no debris or dust is on the heads.

Audit of random sprinkler heads will be completed weekly for 4 weeks to ensure compliance.Audit of the life safety book for sprinkler inspection documentation will be done quarterly to ensure the inspection has been scheduled and completed.

Audit / trends will be reviewed monthly by the safety committee for further recommendations.

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 to positively latch, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on August 5, 2024, between 11:10 AM and 12:05 PM, revealed double corridor doors, with self-closures and latching hardware, did not latch, at the following locations:
a. 11:10 AM, Kitchen, Maintenance Hall side, faulty coordinator;
b. 12:05 PM, Physical Therapy, Main Entrance, faulty coordinator.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the corridor doors failed to positively latch.

Plan of Correction - To be completed: 09/24/2024

The coordinators on the kitchen (maintenance hall side) and the physical therapy main entrance have been adjusted/repaired to positively latch

Doors in the compartment have been observed / checked to positively latch

Audit of the affected doors will be completed weekly for 4 weeks to ensure compliance. Doors will then be audited monthly to ensure compliance

Audit / trends will be reviewed monthly by the safety committee for review and further recommendations

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to provide documentation, verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component.

Findings include:

1. Review of documentation on August 5, 2024, between 8:00 AM and 10:30AM, failed to provide documentation, verifying the 4-year fire damper exercise and cleaning had been conducted.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the facility lacked documentation for fire dampers exercise and cleaning.

Plan of Correction - To be completed: 09/24/2024

Fire damper inspections were performed on time (7/12/24) by a certified contractor

Fire damper inspections are located in section 15.0 of the life safety book

Audit will be performed annually to ensure inspections are in the life safety book.

Audit / trends will be reviewed annually by the safety committee for review and further recommendation.

NFPA 101 STANDARD Electrical Systems - Receptacles:

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 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles to be Ground Fault Interruption (GFI) protected within six feet of a water source, in two of four smoke compartments within the component.

Findings include:

1. Observation on August 5, 2024, between 11:12 AM and 11:40 AM, revealed outlets were not GFI protected and within six feet of a water source, at the following locations:

a. 11:12 AM, Kitchen, Food Preparation Area, 4 outlets;
b. 11:40 AM, Beauty Parlor, by wash sink, 2 outlets.

Interview with the Administrator, Environmental Services Manager and York South Maintenance Director on August 5, 2024, at 1:30 PM, confirmed the outlets were not protected when within six feet of a water source.

Plan of Correction - To be completed: 09/24/2024

4 receptacles in the kitchen and 2 receptacles in the beauty shop have been replaced with GFI protected receptacles

An inspection was performed on receptacles within 6 feet of a water source to determine the need for GFI

Audit of random receptacles to be completed weekly for 4 weeks to ensure compliance. Audit to be conducted yearly to ensure results are included in the life safety book

Audit / trends will be reviewed monthly by the safety committee for further recommendation

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