Pennsylvania Department of Health
 COMPLETE CARE AT LEHIGH LLC
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COMPLETE CARE AT LEHIGH LLC
Inspection Results For:

There are  38 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.
COMPLETE CARE AT LEHIGH LLC - 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 July 23, 2024, at Complete Care of Lehigh, LLC., 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# 044602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 23, 2024, it was determined that Complete Care at Lehigh, LLC., 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 two story, Type II (111), protected, noncombustible building, 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, it was determined the facility failed to ensure that exit access was being maintained readily accessible at all times in two locations, affecting two of two floors.

Findings include:

1. Observation on July 23, 2024, between 9:35 a.m., and 10:12 a.m, revealed the following:

a. At 9:35 a.m., 2nd floor, North exit, had (2) wheelchairs and a lift, stored in the exit access corridor blocking the exit door.

b. At 10:12 a.m., 1st floor, North exit, had (4) caution wet floor signs, a linen cart, and a over the bed table, stored in the exit access corridor blocking the exit door.

Exit interview with the Administration and the Maintenance on July 23, 2024, at 10:30 a.m., confirmed the items stored in the exit access corridor.








 Plan of Correction - To be completed: 09/13/2024

The wheelchairs and the lift at the 2nd floor, North exit was removed at the time it was identified. The caution wet floor signs, linen cart and overbed table at the 1st floor, North exit was removed at the time it was identified.
Staff will be re-educated to not store items at the exit doors to ensure the access to the exit doors is not blocked.
The Maintenance Director or designee will audit the exit doors to ensure access is free from blockages.
Results of the audit and any concerns will be presented at the monthly QAPI meeting for review and/or recommendations.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

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

Findings include:

1. Observation on July 23, 2024, at 10:10 a.m., 1st floor, North stair tower door, failed to latch into frame when tested.

Exit interview with the Administration and the Maintenance on July 23, 2024, at 10:30 a.m., confirmed the stair tower failed to latch.






 Plan of Correction - To be completed: 09/13/2024

The 1st floor, North stair tower door was adjusted to ensure the door fully latches into the frame.
The facility stair tower doors were evaluated to ensure there is proper latching into the frame.
The Maintenance Director or designee will audit the stair tower doors to ensure proper latching into the frames, as part of the monthly preventative maintenance rounds.
Results of the audit and any concerns will be presented at the monthly QAPI meeting for review and/or recommendations.

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 hazardous area enclosures in two locations, affecting two of two floors.

Findings include:

1. Observation on July 23, 2024, between 9:44 a.m., and 10:01 a.m., revealed the following:
a. At 9:44 a.m., 2nd floor, Soiled Utility room near nursing station, had an unsealed penetration of the wall, inside the enclosure.
b. At 9:45 a.m., 2nd floor, Soiled Utility room near nursing station, door failed to latch into frame when tested.
c. At 10:01 a.m., 1st floor, Service Hall, Kitchen/Dietary 2nd entrance, door failed to latch into frame when tested.

Exit interview with the Administration and the Maintenance on July 23, 2024, at 10:30 a.m., confirmed hazardous area enclosure deficiencies.








 Plan of Correction - To be completed: 09/13/2024

The penetration in the wall of the 2nd floor, soiled utility room near the nurse's station was sealed with fire rated drywall. The door to the 2nd floor, soiled utility room near the nurse's station was adjusted to ensure proper latching in the frame. The door on the 1st floor service hall, kitchen/dietary second entrance was adjusted to ensure proper latching in the frame.
The Maintenance Director or designee will audit the walls for penetrations and the doors for proper latching in hazardous areas to ensure the enclosures are smoke resisting partitions, as part of the monthly preventative maintenance rounds.
Results of the audit and any concerns will be presented at the monthly QAPI meeting for review and/or recommendations.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to monitor the installation of alcohol base hand rub dispensers (ABHR) in two locations, affecting two of two floors.

Findings include:

1. Observation on July 23, 2024, between 9:38 a.m., and 10:15 a.m., revealed the following:
a. At 9:38 a.m., 2nd floor, North Hall, corridor wall outside resident room 219, ABHR dispenser located less than one inch from a full addressed fire alarm pull station.
b. At 10:15 a.m., 1st floor, North Hall, corridor wall outside resident room 119, ABHR dispenser located less than one inch from a full addressed fire alarm pull station.

Exit interview with the Administration and the Maintenance on July 23, 2024, at 10:30 a.m., confirmed the ABHR's were installed too close to an ignition source.










 Plan of Correction - To be completed: 09/13/2024

The ABHR dispenser on 2nd floor, North Hall corridor wall outside of room 219 and the dispenser on 1st floor, North Hall corridor wall outside of room 119 have been removed.
ABHR dispensers were audited in the facility to ensure proper installation locations.
The Maintenance Director or designee will audit ABHR dispensers to ensure that they are properly installed in locations that are not within one inch of a fully addressed fire alarm pull station.
Results of the audit and any concerns will be presented at the monthly QAPI meeting for review and/or recommendations.


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