Nursing Investigation Results -

Pennsylvania Department of Health
KINZUA HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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KINZUA HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  36 surveys for this facility. Please select a date to view the survey results.

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KINZUA HEALTHCARE 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 March 10, 2022, at Kinzua Healthcare 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 # 071402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 10, 2022, it was determined that Kinzua Healthcare 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 II (000), unprotected, non-combustible building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 document review and interview, it was determined that the facility failed to maintain fire resistance ratings for smoke barriers, affecting the entire building.

Findings include:

1. Document review on March 10, 2022, at 11:30 a.m., revealed the facility could not provide documentation that the fire/smoke dampers had been exercised within the past four years.

Interview with the maintenance supervisor on March 10, 2022, at 11:30 a.m., confirmed the above damper deficiency at the time of the survey.




 Plan of Correction - To be completed: 05/09/2022

Response:
1. What systemic changes will be put into place to ensure that the deficiency does not recur, and how the corrective actions will be monitored?
a. We have contacted our contractor/inspector. Smoke/fire damper inspection occurred on March 16, 2022.
b. We have instructed our contractor/inspector to place us on an every four year inspection cycle.
c. We have placed a work order in our internal Asset Management system to remind us of the need for inspection every four years.

2. What quality assurance program will be put into place, and the dates when corrective action will be completed?
We have contacted our contractor/inspector for immediate inspection of our fire/smoke barriers. The completion of this inspection did occur on March 16, 2022. Status of the work order will be presented to the QAPI committee next month.

NFPA 101 STANDARD Electrical Systems - Receptacles:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles for one of over fifty rooms.

Findings include:

Observation on March 10, 2022, at 12:59 p.m., revealed the ACU soiled utility room had a receptacle above the sink that was not protected by a ground fault circuit interrupter (GFCI).

Interview with the maintenance supervisor on March 10, 2022, at 12:59 p.m., confirmed the above receptacle deficiency existed.





 Plan of Correction - To be completed: 05/09/2022

Response:
1. What systemic changes will be put into place to ensure that the deficiency does not recur, and how the corrective actions will be monitored?
The outlet in question was replaced on March 14, 2022.
Examination for the necessity of a GFCI outlet has been added to the periodic outlet tension examination work order.
2. What quality assurance program will be put into place, and the dates when corrective action will be completed?
Outcomes of the Examination for the necessity of a GFCI outlet has been added to the periodic outlet tension examination work order will be reported to the QAPI committee for the next three months.


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