Nursing Investigation Results -

Pennsylvania Department of Health
FOX SUBACUTE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FOX SUBACUTE 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.
FOX SUBACUTE 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 September 18, 2019, at Fox Subacute Center 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 # 061102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 18, 2019, it was determined that Fox Subacute Center - Main Building 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 one-story, Type V (000) unprotected wood frame construction, with a basement, which is fully sprinklered.








 Plan of Correction:


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 that the facility failed to maintain the automatic fire sprinkler system components to be free of dust and debris and smoke tight to the ceiling affecting two of three smoke zones within this component.

Findings include:

1. Observation made on September 18, 2019, at 1:45 p.m., revealed that inside central supply room, middle closet sprinkler head was not tight to the ceiling.

Interview at the exit conference with the Administrator and the Maintenance Director on September 18, 2019, at 2:45 pm, confirmed the sprinkler head was not smoke tight.


2. Observation made on September 18, 2019, at 1:50 p.m., revealed that within room 408 there was a sprinkler head which showed evidence of dust and debris load.

Interview at the exit conference with the Administrator and the Maintenance Director on September 18, 2019, at 2:45 pm, confirmed the sprinkler head was not maintained free of debris.






 Plan of Correction - To be completed: 11/15/2019

1. Maintenance Director adjusted the sprinkler escutcheon in the closet in the central supply room to be flush with the ceiling.
2. Maintenance Director will audit all sprinkler heads semi annually
3. Maintenance Director will adjust all sprinkler heads not flush as needed
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: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain/provide portable fire extinguishers from obstructions, affecting one of three smoke zones within this component.

Findings include:

1. Observation made on September 18, 2019 at 1:25 p.m., revealed that portable fire extinguisher cabinets located at Physical therapy room and unit II 205-208, lacked acceptable means of identifying the fire extinguisher locations.

Interview at the exit conference with the Administrator and the Maintenance Director on September 18, 2019, at 2:45 pm, confirmed the location was not identified.







 Plan of Correction - To be completed: 11/15/2019

1. Facility has installed new signage over the fire extinguisher cabinets that were identified, they have a new sign that glows in the dark and extends from the wall to identify the location of the fire extinguisher, the cabinets are also painted red and extend from the wall 2 inches. All other fire extinguishers are wall mounted, with no cabinetry
2. Maintenance Director will inspect all fire extinguisher for ease of visual identification of each fire extinguisher location
3. Maintenance Director will monitor fire extinguisher cabinets quarterly 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 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 that the facility failed to maintain the proper fire resistance rating of the smoke barrier walls, affecting one of three smoke zones within this component.

Findings include:

1. Observation made on September 18, 2019, at 1:30 p.m., within the attic space front office wing, there was an unsealed horizontal penetration of the smoke barrier wall by family room and room 410, around sprinkler piping.

Interview at the exit conference with the Administrator and the Maintenance Director on September 18, 2019, at 2:45 pm, confirmed the penetration.






 Plan of Correction - To be completed: 11/15/2019

1. The unsealed horizontal penetration system UL W-L-1001 through 5/8 inch gypsum board, was sealed with approved fire rated caulk 3M Fire Barrier Sealant, CP 25WB+, Testing UL E ASTM 814 (UL 1479) and ASTM E 84 (UL 723).
2. Maintenance Director will audit facility quarterly for any penetrations of the smoke barrier walls and will repair as needed

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance Pr:This is a less serious (but not lowest level) 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 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.
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0907

Based on document review and interview, it was determined the facility failed to maintain inspections of the piped-in medical gas system, affecting the entire facility.

Findings include:

1. Document review on September 28, 2019, between 9:00 a.m. and 11:00 a.m., revealed the facility failed to provide annual medical gas alarm panels and alarm displays inspection documentation.

Interview at the exit conference with the Administrator and the Maintenance Director on September 18, 2019, at 2:45 pm, confirmed the documentation was unavailable.










 Plan of Correction - To be completed: 11/15/2019

1. The medical gas alarm panel and alarm displays were inspected in August 2019.
2. Facility has contacted our contracted inspection company for the completed reports.
3. Maintenance Director will ensure that all work that is completed at the facility has a completed report to validate completion.
4. Administrator will monitor for completed reports/documentation for all completed work done at the facility
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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, affecting one of three smoke zones within this component.

Findings include:

1. Observation made on September 18, 2019, at 2:00 p.m., revealed there was storage of a chart on wheels and two intravenous stands obstructing access to the electrical circuit breaker panels, inside the storage room across from unit III nurses station.

Interview at the exit conference with the Administrator and the Maintenance Director on September 28, 2019, at 2:45 pm, confirmed the electrical panel were blocked.





 Plan of Correction - To be completed: 11/15/2019

1. The storage chart and two intravenous stands were removed from the storage room
2. Signage was posted to not store any items within this storage room
3. Facility staff will monitor daily for compliance
4. Maintenance Director will monitor weekly for compliance
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) 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 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 Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to maintain identification of essential electrical systems, affecting the entire facility.

Findings include:

1. Observation made on September 18, 2019, at 1:20 p.m., revealed that within the basement circuit breaker room, the critical care branch, life safety branch, and equipment branch, circuitry directory was missing.

Interview at the exit conference with the Administrator and the Maintenance Director on September 28, 2019, at 2:45 pm, confirmed the missing directory.








 Plan of Correction - To be completed: 11/15/2019

1. Maintenance Director will re-label all of the circuitry directory's
2. Maintenance Director will inspect all other circuitry panels to ensure proper labeling and identification and time there is change/replacement to the electrical circuitry, the index will be updated
3. Maintenance Director and Administrator will monitor for compliance quarterly

Initial comments:Name: 8-BED ONE STORY NEW ADDITION - Component: 02 - Tag: 0000


Facility ID # 061102
Component 02
New Addition Wing

Based on a Medicare/Medicaid Recertification Survey completed on September 18, 2019, it was determined that Fox Subacute Center - New Addition Wing 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 one-story, Type V (111), protected wood frame construction, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: 8-BED ONE STORY NEW ADDITION - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, with resistance to the passage of smoke, affecting 1 of 7 resident room corridor doors within this component.

Findings include:

1. Observation made on September 18, 2019, at 2:15 p.m., revealed that room 501 corridor door would not resist the passage of smoke due to a gap greater than a one half (1/2) inch between the active leaf and inactive leaf corridor doors.

Interview at the exit conference with the Administrator and the Maintenance Director on September 18, 2019, at 2:45 pm, confirmed the door was not smoke tight.








 Plan of Correction - To be completed: 11/15/2019

1. The wooden strip was refastened to the door of 501 to resist the passage of smoke
2. Maintenance will inspect all potentially affected doors to ensure that they meet code and resist smoke passage
3. Maintenance Director will audit doors monthly for compliance and adjust as needed

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