Pennsylvania Department of Health
BIRCHWOOD REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 surveys for this facility. Please select a date to view the survey results.

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BIRCHWOOD REHABILITATION & HEALTHCARE 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 June 13, 2024, it was determined that Birchwood Rehabilitation and Healthcare had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:

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(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:
Name: - Component: -- - Tag: 0026

Based on documentation review and interview, it was determined the facility failed to include the role of the facility under a waiver declared by the Secretary of the Department of Health.

Findings include:

1. Observation on June 13, 2024, revealed the facility lacked 1135 Waiver data within the Emergency Preparedness Plan.

Exit interview with the Regional Facilities Manager on June 13, 2024, at 11:55 a.m., confirmed the above deficiency.

Plan of Correction - To be completed: 07/22/2024

E-0026- Emergency Prepared Manual
1. The facilities Emergency Preparedness manual was updated to include the 1135 Waiver data.

2. The Emergency Preparedness manual will be reviewed quarterly at the monthly safety committee meeting.

3. The facility's Safety Director will notify the facility's Quality Assurance and Performance Improvement committee of quarterly updates to the Emergency Preparedness manual.

4. Date of compliance is 7-22-2024.

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

Facility ID# 026402
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on June 13, 2024, it was determined that Birchwood Rehabilitation and Healthcare 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 483.70(a).

This is a two story, Type II (000), unprotected, noncombustible building, that 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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two floors.

Findings include:

1. Observation on June 13, 2024, at 10:03 a.m., revealed the Maintenance Shop door was not smoke-tight.

Exit interview with the Regional Facilities Manager on June 13, 2024, at 11:55 a.m., confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 07/22/2024

K-321- Maintenance Shop Door.
1. Maintenance Shop Door has been corrected.

2. Maintenance Director/Designee will conduct an initial audit of the Maintenance door in the facility to verify that is smoke tight.

3. Nursing Home Administrator/Designee will re-educate the maintenance staff on auditing and correcting doors that are not smoke tight.

4. Maintenance Director/Designee will conduct random audits of the Maintenance Shop door to verify that it is smoke tight weekly for four weeks and then monthly for two months thereafter. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes made as needed.

5. Date of Compliance will be 7-22-2024

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 documentation review and interview, it was determined the facility failed to maintain the building fire alarm system in multiple locations, affecting two of two floors.

Findings include:

1. Observation on June 13, 2024, at 11:07 a.m., revealed the facility lacked documentation that batteries within all battery-operated smoke detection units (located within resident rooms) are changed on a semi-annual basis.

Exit interview with the Regional Facilities Manager on June 13, 2024, between 11:45 a.m., and 11:55 a.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 07/22/2024

K-0345- Resident Room Battery Operated Smoke Detectors
1. The smoke detectors have a 10-year battery life. Install 3/2022.
2. Smoke Detectors are checked monthly and documented in TELS.

NFPA 101 STANDARD Corridor - Doors:

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 the facility failed to maintain corridor openings in three locations, affecting two of two floors.

Findings include:

1. Observation on June 13, 2024, between 10:16 a.m., and 10:50 a.m., revealed the following:

a. 10:16 a.m., the Dietary door required adjustment to fully latch.
b. 10:47 a.m., the first floor, Dining Room doors lacked positive latching hardware (manual slide, dead bolts on internal side only).
c. 10:50 a.m., the first floor, west end, Linen Room door required adjustment to fully close, and latch.

Exit interview with the Regional Facilities Manager on June 13, 2024, at 11:55 a.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 07/22/2024

K-0363 – Dietary Door, 1st floor Dining room Doors and 1st floor west end Linen Room Door.
1. Doors identified have been corrected.

2. Maintenance Director/Designee will conduct an initial audit of the Dietary, 1st floor dining room and 1st floor linen room doors in the facility to verify that they close properly.

3. Nursing Home Administrator/Designee will re-educate the maintenance staff on auditing and correcting doors that fail to close properly.

4. Maintenance Director/Designee will conduct random audits of the Maintenance Shop door to verify that it is smoke tight weekly for four weeks and then monthly for two months thereafter. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes made as needed.

5. Date of Compliance will be 7-22-2024.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 one smoke barrier separation wall, affecting one of two floors.

Findings include:

1. Observation on June 13, 2024, at 10:17 a.m., revealed the second floor smoke barrier separation wall was sealed with drywall tape alone, located above the smoke barrier separation doors, closest to the Director of Nursing Office.

Exit interview with the Regional Facilities Manager on June 13, 2024, at 11:55 a.m., confirmed the smoke barrier separation wall deficiency.

Plan of Correction - To be completed: 07/22/2024

K-0372 – 2nd Floor Smoke Barrier Separation Wall.
1. Smoke Barrier Separation Wall has been Sealed.

2. Maintenance Director/Designee will conduct an initial audit of the smoke separation walls in the facility to verify that they are sealed properly.

3. Nursing Home Administrator/Designee will re-educate the maintenance staff on auditing and correcting smoke separation walls that are not sealed properly.

4. Maintenance Director/Designee will conduct random audits of the 2nd floor smoke separation wall to verify that it is smoke tight weekly for four weeks and then monthly for two months thereafter. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes made as needed.

5. Date of Compliance will be 7-22-2024.

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 01 - Component: 01 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning in multiple locations, affecting two of two floors.

Findings include:

1. Observation on June 13, 2024, at 11:15 a.m., revealed required fire damper preventative maintenance did not include removal of fusible links and exercise of fire dampers (163 fire dampers).

Exit interview with the Regional Facilities Manager on June 13, 2024, at 11:55 a.m., confirmed the HVAC deficiency.

Plan of Correction - To be completed: 07/22/2024

K-0521- Fire Damper Preventative Maintenance.
1. Smoke Dampers were cleaned on 6/23 and Maintenance was done 5/7/24.

2. Documentation is in TELS.

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