Pennsylvania Department of Health
 HOLLAND CENTER FOR REHABILITATION AND NURSING
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HOLLAND CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

There are  45 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.
HOLLAND CENTER FOR REHABILITATION AND NURSING - 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 22, 2024, at Holland Center for Rehabilitation and Nursing, 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# 071202
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on July 22, 2024, it was determined that Holland Center For Rehabilitation And Nursing 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 (222), fire resistive building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain portable, accurate floor plans outlining designated rated partitions, for one of one floor plan.

Findings include:

Document review on July 22, 2024, at 9:50 a.m., revealed the facility failed to provide accurate portable Life Safety Code Floor Plans that included the following information:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan.
e. Required Exits should be clearly noted; and
f. Shafts Walls.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed inaccurate portable floor plans.




 Plan of Correction - To be completed: 08/20/2024

1) Accurate portable Life Safety Code Floor Plans have been obtained.

2) The Maintenance Director has been inserviced on the need to maintain accurate portable Life Safety Floor Plans.

3) An audit will be performed monthly for three months to ensure that an accurate portable Life Safety Floor Plan is maintained.
Results of the audits will be brought to QAPI meeting.
NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of three levels.

Findings include:

Observation on July 22, 2024, at 10:20 a.m., revealed the basement fire doors by the Wellness failed to close and latch when tested.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed the common wall door deficiency.





 Plan of Correction - To be completed: 08/20/2024

1) The basement fire doors by the Wellness center were repaired so that they close and latch when tested.

2) Other fire doors in the center have been checked to ensure that they close and latch.

3)The Maintenance Director will perform audits weekly for four weeks and monthly for two months to ensure that the fire doors close and latch.
Results of the audits will be reported to QAPI meeting.
NFPA 101 STANDARD Egress 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.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined that the facility failed to maintain egress doors with special locking arrangements, affecting one of three levels.

Findings include:

Observation on July 22, 2024, at 11:40 a.m., revealed, second floor stair tower by room 108, the emergency egress door failed to release when the code was entered by staff members.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed the door failed to release when tested.







 Plan of Correction - To be completed: 08/20/2024

1)The second floor stair tower emergency egress door was repaired so that it releases when the code is entered.

2) Other egress doors with special locking arrangements were checked to ensure that they open when the code is entered.

The Maintenance Director and/or designee will conduct an audit weekly for four weeks and monthly for two months to ensure that the egress doors with special locking arrangements open when the code is entered.
Results of these audits will be reported in QAPI meeting.
NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

Based on observation and interview, it was determined that the facility failed to ensure continuous illumination of means of egress on one of three levels.

Findings include:

Observation on July 22, 2024, at 11:45 a.m., revealed the second floor stair tower by room 108 had a light out.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed the burned-out bulb.







 Plan of Correction - To be completed: 08/20/2024

The light in the second floor stair tower by room 108 was replaced.

Other lights that provide illumination to a means of egress have been checked to ensure that they work and provide illumination.

Audits will be conducted weekly for four weeks and monthly for two months to ensure that means of egress are properly illuminated.
Results of the audits will be reported in monthly QAPI meeting.
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 fire extinguisher inspections, affecting one fire extinguisher.

Findings include:

Observation made on July 22, 2024, at 10:30 a.m., revealed the basement electrical room fire extinguisher tag was missing its monthly quick-check inspections.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed the missing monthly quick checks.






 Plan of Correction - To be completed: 08/20/2024

The fire extinguisher in the basement electrical room was checked for the monthly quick check inspection.

Other fire extinguishers were checked to ensure that a monthly quick check was performed.

The Maintenance Director was inserviced regarding performing a monthly quick check on the fire extinguishers.

An audit will be performed weekly for four weeks and monthly for two months by the Maintenance Director and/or designee to ensure that facility fire extinguishers were checked monthly.
Results of these audits will be reported in the monthly QAPI meeting.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting one generator.

Findings include:

Document review on July 22, 2024, at 8:30 a.m., revealed annual fuel quality test results for the emergency generators diesel fuel were not available for review at time of survey.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 08/20/2024

The annual fuel quality test results have been made available.

The Maintenance Director has been inserviced on the need to the correct annual fuel quality results for the emergency generator diesel fuel.

The Maintenace Director and/or designee will be responsible for maintaning the correct annual documentation.

These annual tests will be reported on during monthly QAPI meeting.
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 improper and unauthorized use of electrical devices, affecting one of three levels.

Findings include:

Observation on July 22, 2024, at 10:25 a.m., revealed a microwave and fridge plugged into a power strip, basement Transport Coordinator Office.

Exit interview with the Administrator and Maintenance Director on July 22, 2024, at 12:00 p.m., confirmed the unauthorized electrical device.





 Plan of Correction - To be completed: 08/20/2024

The microwave and fridge have been removed from the power strip in the Transport Coordinator's office.

Other office spaces in the facility will be randomly audited weekly for four weeks and monthly for two months by the Maintenance Director and/or designee to ensure that electrical devices are not being used improperly.
Results of the audits will be reported during monthly QAPI meeting.

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