Nursing Investigation Results -

Pennsylvania Department of Health
COLE PLACE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COLE PLACE
Inspection Results For:

There are  35 surveys for this facility. Please select a date to view the survey results.

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COLE PLACE - 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 30, 2022, at Cole Place, 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# 031802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2022, it was determined that Cole Place, 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 structure, with loft and crawl spaces, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting two of five smoke compartments.

Findings include:

1. Observation on June 30, 2022, at 8:30 a.m., revealed unprotected structural steel was located within the west elevator shaft enclosure, at the first and second floor levels.

Exit interview with the Facility Administrator and Facility Representative #1 on June 30, 2022, at 11:40 a.m., confirmed the unprotected structural steel.




 Plan of Correction - To be completed: 08/01/2022

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. Maintenance will coat the exposed steel within the west elevator shaft enclosure at the first and second floor levels with a 2 -hour fire resistant coating. The maintenance department will inspect the elevator shaft to ensure there are no additional areas of exposed steel; any additional areas will be corrected upon discovery.

2. The corrective action and inspection will be completed by August 1, 2022. The Facilities Manager is responsible to ensure that these inspections are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 smoke barrier walls to provide at least a one-half hour fire resistance rating, affecting two of five smoke compartments.

Findings include:

1. Observation on June 30, 2022, at 10:00 a.m., revealed unsealed penetrations located above the door, in the attic level, on the OR side.

Exit interview with the Facility Administrator and Facility Representative #1 on June 30, 2022, at 11:40 a.m., confirmed the penetrations.




 Plan of Correction - To be completed: 08/01/2022

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1.The penetrations (above the door in the attic level on the OR side) were identified and will be sealed using fire resistant rated caulking to maintain the required smoke barrier wall. Upon completion, the maintenance department will inspect the area to ensure all penetrations are properly sealed.

2.The corrective action and inspection will be completed by August 1, 2022. The Facilities Manager is responsible to ensure that these inspections are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors, affecting two of five smoke compartments.

Findings include:

1. Observation on June 30, 2022, between 10:25 a.m. and 10:45 a.m., revealed the following:

a. 10:25 a.m. - The smoke barrier doors near the administrative area do not seal when closed.
b. 10:45 a.m.- The smoke barrier doors located near resident room #15 had an inoperable door coordinator.

Exit interview with the Facility Administrator and Facility Representative #1 on June 30, 2022, at 11:40 a.m., confirmed the lack of a door seal and inoperable door coordinator.




 Plan of Correction - To be completed: 08/01/2022

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

A
1. The smoke barrier doors near the administrative area will be adjusted to seal the gap identified upon closure of the doors. Upon completion of this adjustment, the maintenance department will inspect the smoke barrier doors within Cole place for any gaps or seal issues.

2. The corrective action and inspection will be completed by August 1, 2022. The Facilities Manager is responsible to ensure that these inspections are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.


B.
1. The inoperable door coordinator on the smoke barrier doors near resident room 15 will be replaced. Upon completion of this repair, the maintenance department will inspect the applicable doors within Cole Place for functioning door coordinators and schedule any necessary corrective action.

2. The corrective action and inspection will be completed by August 1, 2022. The Facilities Manager is responsible to ensure that these inspections are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.

NFPA 101 STANDARD Electrical Equipment - Other: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 - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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.
Chapter 10 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, affecting one of five smoke compartments.

Findings include:

1. Observation on June 30, 2022, at 9:55 a.m., revealed an open electrical junction box located in the attic area.

Exit interview with the Facility Administrator and Facility Representative #1 on June 30, 2022, at 11:40 a.m., confirmed the exposed electrical wires.




 Plan of Correction - To be completed: 08/01/2022

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. A cover will be installed on the open electrical junction box located in the attic area. The maintenance department will inspect the area for any open junction boxes within Cole Place and coordinate any necessary corrective action.

2. The corrective action and inspection will be completed by August 1, 2022.The Facilities Manager is responsible to ensure that this inspection and repair are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.


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