Nursing Investigation Results -

Pennsylvania Department of Health
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  41 surveys for this facility. Please select a date to view the survey results.

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MOUNTAIN LAUREL HEALTHCARE 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 December 16-17, 2019, it was determined that Mountain Laurel Healthcare and Rehabilitation Center, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.





 Plan of Correction:


483.73(d) REQUIREMENT EP Training and Testing: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.
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at 483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. The ICF/IID must meet the requirements for evacuation drills and training at 483.470(h).

*[For ESRD Facilities at 494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be reviewed and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on December 16, 2019, at 9:00 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes an annual emergency management training and testing for all staff.

Interview with the maintenance director on December 16, 2019, at 9:00 a.m., confirmed the Emergency Preparedness Plan did not include the above elements.






 Plan of Correction - To be completed: 01/06/2020

1. What systemic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

Facility staff will be In-serviced and tested on the facility Emergency Preparedness Plan by 1/6/20.

2. What quality assurance program will be put into place, and the dates when the corrective action will be completed;

The Maintenance Director/designee will provide evidence of training and testing of the facility Emergency Preparedness Plan to the QAPI Committee during the January 2020 QAPI Committee Meeting to ensure completion and compliance.

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


Facility ID # 032702
Component 01
Main Building (A & B Wings)

Based on a Medicare/Medicaid Recertification Survey completed on December 16-17, 2019, it was determined that Mountain Laurel Healthcare 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 III (200), unprotected, ordinary building, with a partial basement, that is fully sprinklered.






 Plan of Correction:


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 01 - Component: 01 - Tag: 0211

Based on observation and interview, the facility failed to maintain means of egress, free of all obstructions to full use in case of emergency, at one of three basement exits.

Findings include:

1. Observation on December 17, 2019, at 10:45 a.m., revealed the basement exit discharge to the outside (closest to maintenance office), had 1 and 1/2 inches of water accumulated at the bottom landing of the stair that leads to a public way. Freezing temperatures may cause this water to freeze, making this exit impassable.

Interview with the maintenance director on December 17, 2019, at 10:45 a.m., confirmed the above exit discharge is not free of water accumulation.








 Plan of Correction - To be completed: 01/06/2020

K 0211

1. What systemic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

The basement exit discharge to the outside (closest to the Maintenance Office) will be treated during freezing temperatures with ice melt, as all exit areas and sidewalks are treated. A container of ice melt will be kept at the exit during winter months to treat the area as needed. The Maintenance Director/designee will observe 3 exit areas per week to ensure they are clear and safe for exit in the event of an emergency. Audits will continue until 3 consecutive months of compliance are achieved.

2. What quality assurance program will be put into place, and the dates when the corrective action will be completed;

The Maintenance Director/designee will present the results of the exit way audits to the QAPI Committee during monthly QAPI Committee to ensure completion and compliance.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID # 032702
Component 02
A Wing Annex

Based on a Medicare/Medicaid Recertification Survey completed on December 16-17, 2019, at Mountain Laurel Healthcare and Rehabilitation Center, it was determined there were no deficiencies identified under the 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 II (000), unprotected, noncombustible building, that is fully sprinklered.






 Plan of Correction:


Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000


Facility ID # 032702
Component 03
Unit C

Based on a Medicare/Medicaid Recertification Survey completed on December 16-17, 2019, it was determined that Mountain Laurel Healthcare 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 three-story, Type II (222), fire resistive 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 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.
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: BUILDING 03 - Component: 03 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous areas at one of over ten hazardous areas.

Findings include:

1. Observation on December 16, 2019, at 11:35 a.m., revealed the facility staff bypassed the coordinator on the first floor laundry double doors (closest to dietary storage). When the coordinator is bypassed, the astragal prevents the doors from latching in the frame.

Interview with the maintenance director on December 16, 2019, at 11:35 a.m., confirmed the above double doors were not latched in the frame.








 Plan of Correction - To be completed: 01/06/2020

1. What systemic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

The Laundry/Housekeeping staff were re-educated on not propping doors open. The Maintenance Director/designee will conduct random of audits of 4 automatic-closing or self-closing doors per week to ensure the doors are closing properly. Audits will continue until 3 consecutive months of compliance are achieved.

2. What quality assurance program will be put into place, and the dates when the corrective action will be completed;

The Maintenance Director/designee will present the results of the door audits will be presented to the QAPI Committee during monthly QAPI Meetings to ensure completion and compliance.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: BUILDING 03 - Component: 03 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cords in one of over twenty-five rooms.

Findings include:

1. Observation on December 17, 2019, at 9:50 a.m., revealed the first floor, physical therapy office, had a microwave oven and a refrigerator plugged into a surge protection/battery back-up device.

Interview with the maintenance director on December 17, 2019, at 9:50 a.m., confirmed the above appliances were not plugged directly into an electrical receptacle.






 Plan of Correction - To be completed: 01/06/2020

1. What systemic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

Staff, including the therapy department, will be re-educated on plugging microwave ovens and refrigerators directly into electrical receptacles and not into surge protectors or extension cords by 1/6/20. The Maintenance Director/designee will conduct random audits of 3 areas containing microwave ovens and/or refrigerators weekly to ensure they are properly plugged directly into electrical receptacles. The audits will continue until 3 consecutive months of compliance is achieved.


2. What quality assurance program will be put into place, and the dates when the corrective action will be completed;

The Maintenance Director/designee will present the results of the microwave/refrigerator audits to the QAPI Committee at the monthly QAPI Committee Meetings to ensure completion and compliance.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000


Facility ID # 032702
Component 04
B Wing Annex

Based on a Medicare/Medicaid Recertification Survey completed on December 16-17, 2019, at Mountain Laurel Healthcare and Rehabilitation Center, it was determined there were no deficiencies identified under the 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 II (000), unprotected, noncombustible building, that is fully sprinklered.





 Plan of Correction:



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