Nursing Investigation Results -

Pennsylvania Department of Health
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Building Inspection Results

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T - 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 February 25, 2020, at The Summit at Blue Mountain 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: SKIILED NURSING - Component: 01 - Tag: 0000


Facility ID# 070502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 25, 2020, it was determined that The Summit at Blue Mountain Nursing 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 three story, Type III (200), unprotected, ordinary building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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: SKIILED NURSING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting five of five smoke compartments.

Findings include:

1. Observation on February 25, 2020, at 9:00 a.m., revealed the building story height exceeded the maximum allowable number of stories for this type of construction.

Exit interview with facility representatives #1 and #2 on February 25, 2020, at 12:00 p.m., confirmed the building construction height.




 Plan of Correction - To be completed: 04/07/2020

Facilities Director/designee intends to resubmit our petition for reclassification of building structure and type to the PA DOH DSI. This petition had been submitted in May 2019, but subsequently withdrawn in July 2019 after consultation with the PA DOH DSI and holding belief that the option to use a pre-existing 2001 FSES would be reinstated by CMS. Since despite, commentary in support of the reinstatement had been received by CMS, no action has been taken on the matter to date, thus requiring a change in our position in regards to a mitigation plan. The core point of the petition is the request to change building structure and type classification from Type III(200) to two-story with a basement. When classified by strict definition of 2012 NFPA 101, Paragraphs 3.3.83.1 (1) and 4.6.3(1) and (2), the structure should be considered a two-story structure with basement since the Level of Exit Discharge (LED) is actually located at the 2st Floor and not the Basement/Ground Floor.
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: SKIILED NURSING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors, affecting one of five smoke compartments.

Findings include:

1. Observation on February 25, 2020, at 10:30 a.m., revealed the 1st floor staff lounge corridor door could not close and latch.

Exit interview with facility representatives #1 and #2 on February 25, 2020, at 12:00 p.m., confirmed the corridor door could not close and latch.




 Plan of Correction - To be completed: 04/07/2020

First floor staff lounge door was adjusted to achieve positive latching.

Weekly rounding will be completed by maintenance staff, random doors will be checked throughout the facility for positive latching. Any doors found to be lacking positive latching will be repaired.

Results of random checks preformed by maintenance will be reported at monthly QAPI.
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: SKIILED NURSING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting two of five smoke compartments.

Findings include:

1. Observation on February 25, 2020, at 10:45 a.m., revealed the 1st floor smoke barrier wall had an unsealed penetration above the cross-corridor doors located near the nurse's station.

Exit interview with facility representatives #1 and #2 on February 25, 2020, at 12:00 p.m., confirmed the smoke barrier wall penetration.




 Plan of Correction - To be completed: 04/07/2020

First floor smoke barrier wall above the cross-corridor doors located near the nurse's station penetration was filled Hilti fire rated caulk.

Monthly rounding completed by maintenance staff will include random audits through out the facility for fire/smoke barrier penetration.

Results of the audits preformed by maintenance will reported at the monthly QAPI.


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: SKIILED NURSING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, affecting three of five smoke compartments.

Findings include:

1. Observation on February 25, 2020, between 9:15 a.m. and 11:00 a.m., revealed:

a. 9:15 a.m. - Resident room #218 had an extension cord in use.

b. 9:30 a.m. - The front entrance (aquarium) had a multi-outlet plugged into an electrical receptacle.

c. 11:00 a.m. - The basement level business office had a triple plug extension cord in use.

Exit interview with facility representatives #1 and #2 on February 25, 2020, at 12:00 p.m., confirmed the unauthorized use of extension cords and a multi-outlet.




 Plan of Correction - To be completed: 04/07/2020

Resident room 218 extension cord was removed. The front entrance (aquarium) had an additional hardwire outlet added. The basement level business office extension cord was removed and replaced with UL approved hospital grade power strip.

Staff will be re-educated in regards to no extension cords may be used in residents rooms or office space.

Monthly rounding completed by maintenance staff will include random audits of resident rooms and office spaces to ensure no unapproved devices are in use.

Results of the random audits preformed by maintenance will be reported at monthly QAPI.



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