Pennsylvania Department of Health
NORRITON SQUARE NURSING AND REHABILITATION CENTER
Building Inspection Results

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NORRITON SQUARE NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  49 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.
NORRITON SQUARE 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 April 15, 2024, at Norriton Square 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: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 068202
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2024, it was determined that Norriton Square 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 three-story, Type II (111), protected noncombustible building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
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 document review and interview, it was determined the facility failed to ensure the kitchen suppression system was maintained, affecting one of three levels.

Findings include:

Document review on April 15, 2024, at 9:30 a.m., revealed the January 9, 2024, kitchen exhaust hood cleaning report noted the following compliance issue, which remained uncorrected at time of survey: " Hinge kits needed for fans- unable to remove/tip fan. "

Exit Interview with the Administrator and Maintenance Director on April 15, 2024, at 12:00 p.m., confirmed the kitchen hood deficiency.





 Plan of Correction - To be completed: 06/04/2024


1. The Maintenance department reached out to the vendor to reinspect and replace hinge kits for the kitchen exhaust hood.
2. The Maintenance Director or designee will conduct an initial audit to ensure Hinge kits are in place and the kitchen exhaust hood is cleaned.
3. The Maintenance Director or designee will conduct random monthly audits x 3 months to ensure hinge kits are in place and kitchen exhaust hood is cleaned.
4. The Maintenance Director or designee will report findings at monthly safety meetings to the Safety Committee x 3 months.

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 document review and interview, it was determined the facility failed to maintain sprinkler system components, affecting the one of three levels.

Findings include:

Document review on April 15, 2024, at 9:00 a.m., revealed the August 7, 2023, Annual sprinkler inspection report listed the following deficiency: Piping covered in fire spray; on the first floor, mechanical room. Evidence of corrective action was not available at time of survey:

Exit Interview with the Administrator and Maintenance Director on April 15, 2024, at 12:00 p.m., confirmed the sprinkler system deficiency.





 Plan of Correction - To be completed: 06/04/2024

1. The Maintenance department removed fire spray immediately from piping on the first floor and mechanical room upon Life Safety exit.
2. The Maintenance Director or designee will conduct monthly audits x 3 months to ensure piping remains uncovered on the first floor and mechanical room.
3. The Maintenance Director or designee will report findings at monthly safety meetings to the Safety Committee x 3 months.

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 the facility failed to maintain the fire rating of the smoke barrier walls, affecting two of three levels.

Findings include:

Observations on April 15, 2024, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 11:00 a.m., on the first floor, above smoke doors to service hall, around data wires.
b. 11:45 a.m., on the second floor above smoke doors by 211, around MC cable.

Exit Interview with the Administrator and Maintenance Director on April 15, 2024, at 12:00 p.m., confirmed the penetrations.





 Plan of Correction - To be completed: 06/04/2024

1. The Maintenance department sealed the open penetration on the first floor above smoke doors to the service hall and by room 211 around MC cable using an UL approved stop gap penetration system
2. The Maintenance Director or designee will conduct an initial audit to ensure all smoke barrier walls penetration remain sealed with UL approved stop gap penetration system.
3. The Maintenance Director or designee will conduct monthly audits x 3 months to ensure all smoke barrier walls have sealed UL approved stop gap penetrations.
4. The Maintenance Director or designee will report findings at monthly safety meetings to the Safety Committee x 3 months.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of three levels.

Findings include:

Observation on April 15, 2024, at 10:30 a.m., revealed on the first floor CRC office, microwave and fridge plugged into a surge protector.

Exit Interview with the Administrator and Maintenance Director on April 15, 2024, at 12:00 p.m., confirmed the unauthorized electrical device.





 Plan of Correction - To be completed: 06/04/2024

1. Maintenance department immediately removed the surge protector from CRC's office and provided immediate education.
2. The Maintenance Director or designee will provide education to Department Heads on the use of surge protectors prohibited into duplex receptacles.
3. Maintenance Director or designee will conduct random monthly audits x's 3 to ensure microwave and refrigerator are plugged directly into the duplex receptacle.
4. The Maintenance Department or designee will report findings at monthly safety meetings x's 3 months.

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 storage of oxygen cylinders, affecting one of three levels.

Findings include:

Observation on April 15, 2024, at 10:20 a.m., revealed an unsecured oxygen cylinder, on the second floor, in oxygen storage closet.

Exit Interview with the Administrator and Maintenance Director on April 15, 2024, at 12:00 p.m., confirmed the unsecured oxygen cylinder.





 Plan of Correction - To be completed: 06/04/2024


1. Nursing Management immediately secured the oxygen cylinder in the proper holder in the storage room.
2. The Maintenance Director or designee will conduct an initial audit to ensure oxygen cylinders are secured in cylinder holders in the storage room.
3. The Maintenance Director or designee will conduct weekly audits x 12 to ensure oxygen cylinders are secured in cylinder holders in the storage room.
4. The Maintenance Director or designee will report findings at monthly safety meetings 3X to the Safety Committee meeting.


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