Pennsylvania Department of Health
 BRINTON MANOR NURSING AND REHABILITATION CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BRINTON MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

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

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
BRINTON MANOR 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 May 22, 2024, at Brinton Manor 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: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0000


Facility ID# 033502
Component 01
Main Building & Dining Room

Based on a Medicare/Medicaid Recertification Survey completed on May 22 2024, it was determined that Brinton Manor Nursing And Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 building, with a basement and an attic, 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: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0211

Based on observation, document review, and interview, it was determined the facility failed to ensure exits were readily accessible, without obstructions, affecting one of two levels.

Findings include:

1. Observation and document review on May 22, 2024, between 9:00 a.m. and 10:30 a.m., revealed headroom, Basement, exit access corridor was five feet eight inches, due to building service pipes. This was below the six-foot eight-inch minimum requirement.

Exit Interview with the Adminstrator, Maintenance Director, and Property Manager on May 22, 2024, at 12:45 p.m., confirmed the head room was below the required height.


2. Observation and document review on May 22, 2024, between 9:00 a.m. and 10:30 a.m., revealed the exit stairway door headroom was six feet three inches, Basement, which is below the six foot eight inch minimum requirement.

Exit Interview with the Adminstrator, Maintenance Director and Property Manager on May 22, 2024 at 12:45 p.m., confirmed the head room was below the minimum height requirement.


3. Observation and interview on May 22, 2024 at 11:50 a.m. revealed one of two double egress doors at sunroom (vending machine room) were blocked by multiple stored wheelchairs.

Exit Interview with the Adminstrator, Maintenance Director, and Property Manager on May 22, 2024 at 12:45 p.m., confirmed the stored wheelchairs blocking opening swing of egress door.









 Plan of Correction - To be completed: 07/02/2024

1. Facility requests DOH Life Safety to perform a new FSES on both exit access corridors not meeting 6'8 minimum requirement
2. We removed wheel chairs from blocking double egress doors at sunroom
3. Education provided by NHA/Designee to Maintenance Director and Nursing Staff on not blocking egress doors
4. NHA/Designee will audit egress doors weekly x4 weeks to ensure compliance
5. All findings will be reviewed in QAPI meeting

NFPA 101 STANDARD Number of Exits - Story and Compartment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0241

Based on observation, document review, and interview, it was determined the facility failed to maintain two acceptable exits, affecting one of five smoke compartments.

Findings Include:

Observation and document review on May 22 2024, between 9:00 a.m. and 10:30 a.m., revealed the remote fire exit leads onto the first floor, Activities Room, from the Basement, in lieu of directly outside.

Exit interview with the Adminstrator, Maintenance Director, and Property Manager on May 22, 2024, at 12:45 p.m., confirmed the basement exit stairway did not lead directly to the outside.







 Plan of Correction - To be completed: 07/02/2024

1. Facility requests DOH Life Safety to perform a new FSES
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of two levels.

Findings Include:

Observation on May 22, 2024 at 11:45 a.m., outside room 114 revealed a fire extinguisher cabinet missing door handle hardware.

Exit Interview with the Administrator, Maintenance Director, and Property Manager on May 22, 2024, at 12:45 p.m., confirmed the missing cabinet hardware.







 Plan of Correction - To be completed: 07/02/2024

1. Fire extinguisher cabinet door handle fixed and fastened to door appropriately
2. Education provided by NHA/Designee to Maintenance Director on proper Fire Extinguisher Door maintenance
3. NHA/Designee will audit fire extinguisher doors weekly x4 weeks to ensure compliance
4. All findings will be reviewed in QAPI meeting

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: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0374

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

Findings include:

Observation on May 22, 2024, at 11:15 a.m., revealed on the first floor, a smoke door missing its self-closing device, the smoke doors entering to 300-wing.

Exit Interview with the Administrator, Maintenance Director, and Property Manager on May 22, 2024, at 12:45 p.m., confirmed the missing closer.





 Plan of Correction - To be completed: 07/02/2024

1. Self closing device to be fixed on smoke doors entering to the 300 wing.
2. Education provided by NHA/Designee to Maintenance Director on Smoke Doors
3. NHA/Designee will audit Smoke Doors weekly x4 weeks to ensure compliance
4. All findings will be reviewed in QAPI meeting

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: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain designated smoking areas, affecting one of two levels.

Findings include:

Observation on March 22, 2024, at 10:35 a.m., revealed, the designated smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area and not in the provided ash receptacles.

Exit Interview with the Administrator, Maintenance Director, and Property Manager on May 22, 2024, at 12:45 p.m., confirmed the discarded cigarette butts.




 Plan of Correction - To be completed: 07/02/2024

1. Designated smoking area to be put on regular checks and maintained appropriately
2. Education provided by NHA/Designee to Maintenance Director on maintaining the designated smoking areas.
3. NHA/Designee will audit smoking area weekly x4 weeks to ensure compliance
4. All findings will be reviewed in QAPI meeting

NFPA 101 STANDARD Electrical Systems - 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 Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99)
Observations:
Name: BUILDING 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to comply with NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment, affecting one of two levels in the facility.

Findings include:

1. Observation on May 22, 2024, at 10:45 a.m., inside boiler room revealed a electrical taped junction box cover. Undersized cover to fit junction box.

Exit interview with the Adminstrator, Maintenance Director, and Property Manager on May 22 2024, at 12:45 p.m., confirmed missing cover.


2. Observation on May 22, 2024, at 11:00 a.m., revealed a switch/receptacle combo with exposed inner wiring, due to a missing cover plate, on the first floor, 300 wing.

Exit Interview with the Adminstrator, Maintenance Director, and Property Manager on May 22 2024, at 12:45 p.m., confirmed the missing cover plate.












 Plan of Correction - To be completed: 07/02/2024

1. Electrical tape removed and Cover Plates installed on both junction boxes
2. Education provided by NHA/Designee to Maintenance Director on electrical wiring and equipment
3. NHA/Designee will audit identified cover plates weekly x4 weeks to ensure compliance
4. All findings will be reviewed in QAPI meeting

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - 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 01 (ORIGINAL/DINING ROOM COMBINED) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper use of outlet multipliers, affecting one of two levels in the facility.

Findings include:

Observation on May 22, at 11:00 a.m., revelaed on the first floor, inside room 308, there was an outlet multiplier in use.

Exit Interview with the Adminstrator, Maintenance Director, and Property Manager on May 22 2024, at 12:45 p.m., confirmed the improper use of a outlet multiplier.








 Plan of Correction - To be completed: 07/02/2024

1. Outlet multiplier removed from room
2. Education provided by NHA/Designee to Maintenance Director on proper use of outlet multipliers
3. NHA/Designee will audit identified resident room weekly x4 weeks to ensure compliance
4. All findings will be reviewed in QAPI meeting


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance


Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement
Visit the PA Power Port