Nursing Investigation Results -

Pennsylvania Department of Health
MOUNTAIN VIEW CARE AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MOUNTAIN VIEW CARE AND REHABILITATION CENTER
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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MOUNTAIN VIEW CARE 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 January 6, 2020, it was determined that Mountain View Care 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)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on documentation review and interview, it was determined the facility failed to conduct a full-scale exercise of the Emergency Management plan.

Findings include:

1. Observation on January 6, 2020, at 11:05 a.m., revealed the facility lacked a comprehensive, full-scale exercise of the Emergency Management Plan within the last twelve month period.


Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the facility lacked an emergency management full-scale exercise.




 Plan of Correction - To be completed: 01/22/2020

F tag 0039 A full scale comprehensive exercise drill on Emergency preparedness plan. The local fire department was in attendance along with all employees from the facility.
The agenda and sign in sheet were not available at the time of survey due to staff turnover. The facility located the appropriate documentation. The drill was conducted on 06/12/2019.
Education was provided to the maintenance Director on the guidelines of the Emergency Preparedness Plan.
The safety team will monitor the requirements and report their findings to the QAPI Team.

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


Facility ID# 053602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 6, 2020, it was determined that Mountain View Care 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 V (111), protected, wood frame building, with an unused attic space, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of one floor.

Findings include:

1. Observation on January 6, 2020, at 9:44 a.m., revealed the gypsum board portion of the rated ceiling assembly within the boiler room was loose.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the building construction deficiency.



 Plan of Correction - To be completed: 01/22/2020

F tag 0161 The dry wall that was loose was repaired and fire caulked on 01/10/2019.
The maintenance department will complete an inspection to make sure we are in compliance with F tag 0161. They will report their findings to the facility QAPI team.
The Maintenance Director or designee will monitor.

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 three hazardous area enclosures, affecting one of one floor.

Findings include:

1. Observation on January 6, 2020, between 9:40 a.m. and 10:10 a.m., revealed the following:

a. 9:40 a.m., the plant operations door required adjustment to fully latch.
b. 9:45 a.m., the laundry room door required adjustment to fully latch.
c. 10:10 a.m., the medical records office door was held open by unapproved means (door chock).

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the hazardous area enclosure deficiencies.




 Plan of Correction - To be completed: 01/22/2020

F tag 0321 The Plant operations door, the laundry room door was repaired. The door stopper was removed immediately from medical records. This was completed 01/06/2020.
Audits will be conducted weekly for 2 months to assure the doors are operating correctly and that there is not any unapproved item holding doors open.
The Maintenance Director or designee will monitor and all findings will be reported to the facility QAPI team.
The staff will be educated, and the Maintenance Director will monitor.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities, affecting one of one floor.

Findings include:

1. Observation on January 6, 2020, at 10:57 a.m., revealed the facility lacked evidence of one of two required dietary range hood exhaust duct cleanings.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the cooking facilities deficiency.



 Plan of Correction - To be completed: 01/22/2020

F tag 0324 The range hood exhaust duct was cleaned according to regulations/ The paperwork good not be located at the time of survey. It was cleaned on 07/10/20019 and 12/23/2019
Audits will be conducted weekly for 2 months on cleaning of hood will be conducted to be assured that it is cleaned according to regulation.
The Maintenance Director or designee will monitor for compliance and all findings will be reported to the QAPI team.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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.

Findings include:

1. Observation on January 6, 2020, at 10:50 a.m., revealed the facility lacked a biennial smoke detection sensitivity test.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the facility lacked a current biennial smoke detection sensitivity test.



 Plan of Correction - To be completed: 01/22/2020

F tag 0345 A biennial smoke detection sensitivity was completed on 10/16/2019. The paperwork was not available during the survey.
Audits will be conducted weekly for 2 months to be assured that the testing will be conducted according to regulation.
The Maintenance Director or designee will monitor this and report all findings to the QAPI team.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three locations, affecting one of one floors.

Findings include:

1. Observation on January 6, 2020, between 9:35 a.m. and 10:30 a.m., revealed the following:

a. 9:35 a.m., four sprinkler head assemblies, located at the exterior canopy, lacked escutcheon plates.
b. 10:30 a.m., access to the sprinkler standpipe was blocked by miscellaneous storage items.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiencies.




 Plan of Correction - To be completed: 01/22/2020

F tag 0353 The escutcheon plates were installed to the 4 outside sprinkler heads.
The housekeeping storage carts were removed from blocking the access to the sprinkler standpipe.
Audits will be conducted weekly for 2 months to be assured we are in compliance with the regulation. All findings will be reported to the QAPI team.
The Maintenance Director or designee will monitor for compliance.

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 one set of smoke barrier separation doors, affecting one of one floor.

Findings include:

1. Observation on January 6, 2020, at 10:06 a.m., revealed the B hallway smoke barrier separation doors required adjustment to fully close.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the smoke barrier separation door deficiency.



 Plan of Correction - To be completed: 01/22/2020

F tag 0374 The B wing smoke barrier doors were adjusted.
Audits will be conducted weekly for 2 months to be assured all smoke barrier doors are in working properly and all findings will be report to the QAPI team.
Education will be provided.
The Maintenance Director or designee will monitor for compliance.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to conduct one of twelve fire drills.

Findings include:

1. Observation on January 6, 2020, at 10:52 a.m., revealed the facility lacked a second shift fire drill for the first quarter of calendar year 2019.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the fire drill deficiency.




 Plan of Correction - To be completed: 01/22/2020

F tag 0712 The 2nd shift fire drill was completed on February 28, 2019. The maintenance Director accidently putting the wrong date. He knew it was the last day of the month and he put the 31st down instead of the 28th.
All fire drills were completed and conducted according to regulation.
The Maintenance Director or designee will monitor and report all findings to the QAPI team.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of one floor.

Findings include:

1. Observation on January 6, 2020, at 10:16 a.m., revealed the unsecured "e-style" oxygen cylinder were located within the oxygen storge room.

Exit interview with the facility administrator and the facilities manager on January 6, 2020, between 11:20 a.m. and 11:30 a.m., confirmed the cylinder storage deficiency.



 Plan of Correction - To be completed: 01/22/2020

F tag 0923 All E tanks will be stored in an E container cart. More carts were delivered.
House Keeping staff will be educated on the proper storage of oxygen tanks.
Audits will be conducted weekly for 2 months to be assured that the E tanks are being stored properly.
The Maintenance Director or designee will monitor and report all findings to the QAPI team.


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