Nursing Investigation Results -

Pennsylvania Department of Health
NORTHAMPTON COUNTY HOME- GRACEDALE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORTHAMPTON COUNTY HOME- GRACEDALE
Inspection Results For:

There are  62 surveys for this facility. Please select a date to view the survey results.

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NORTHAMPTON COUNTY HOME- GRACEDALE - 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 June 29, 2022, at Northampton County Home-Gracedale, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: NORTHWEST WING - Component: 01 - Tag: 0000


Facility ID# 072802
Component 01
Building 01
Northwest Wing

Based on a Medicare/Medicaid Recertification Survey completed June 28-29, 2022, it was determined that Northampton County Home-Gracedale, 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 two story, Type III (200), unprotected ordinary building, with a basement, basement-level crawl space, and unused attic, 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: NORTHWEST WING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements on three of three floors.

Findings include:

1. Observation on June 28, 2022, between 10:30 a.m. and 12:30 p.m., revealed the facility exceeded the maximum allowable story height for the type of construction.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the facility exceeded the maximum allowable story height for an unprotected ordinary type of building construction.




 Plan of Correction - To be completed: 08/29/2022

Request for continuation of FSES.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain one vertical opening in one location, affecting two of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:29 a.m., revealed a penetration of the floor slab assembly, located within the basement-level, OTR area.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the vertical opening deficiency.



 Plan of Correction - To be completed: 08/28/2022

Penetration in floor slab will be properly repaired in OTR area. Reference to issue track #127335. Staff will be re-educated on identifying unsealed penetrations. Maintenance designee will report findings at QAPI.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:40 a.m., revealed the basement-level, Therapeutic Recreation Director's Office door lacked a self-closing device, required due to aggregate amount of combustible storage located within.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the hazardous area enclosure deficiency.



 Plan of Correction - To be completed: 08/28/2022

Therapeutic Recreation office will be cleared and all items properly stored alleviating the need for a self closing device. Re-education provided to staff advising of proper storage of office items. Maintenance designee will report findings at QAPI.
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: NORTHWEST WING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting two of three floors.

Findings include:

1. Observation on June 28, 2022, between 10:36 a.m., and 11:33 a.m., revealed the following:

a. 10:36 a.m., an escutcheon plate was missing from a sprinkler head assembly within the second floor, northwest storage room.
b. 11:33 a.m., ceiling tiles were lacking within the basement-level, TR area.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiencies.




 Plan of Correction - To be completed: 08/28/2022

1.a) NW Storage room sprinkler escutcheon reinstalled. Reference to issue trak#127336. Staff re-educated in identifying unsealed penetrations.
b). Ceiling tiles replaced in basement level TR Area. Reference to Issue Trak # 127337. Staff re-educated in identifying missing tiles. Maintenance designee will report findings at QAPI.
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: NORTHWEST WING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, between 11:09 a.m., and 11:16 a.m., revelaed the following:

a. 11:09 a.m, the NW1-22 door was not smoke-tight.
b. 11:16 a.m., a rag precluded the NW2-10 door from fully closing and latching.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 08/28/2022

1. a) Door will be adjusted to proper closing force ensuring smoke tight conditions. Reference to Issue Trak# 127338. Staff re-educated to identify ill fitting doors.
1.b) Rag removed and assured door properly closed and latched. Staff re-educated on properly closing and latching doors. Maintenance designee will report findings to QAPI.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: NORTHWEST WING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in two instances, affecting one of two floors in this component.

Findings include:

1. Observation on June 28, 2022, between 10:30 a.m., and 12:30 p.m., revealed two second floor smoke barrier walls did not extend through the attic to the deck above.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the 2nd floor smoke barrier walls do not extend to the underside of the roof deck.




 Plan of Correction - To be completed: 08/28/2022

Request for continuation of FSES.
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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:27 a.m., revealed the distance between the first floor, number thirty two and thirty three smoke barrier doors, exceeded one-eighth-inch

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the smoke barrier door deficiency.



 Plan of Correction - To be completed: 08/28/2022

Gap between door #32 and #33 to be repaired with proper astragal. Reference to issue trak# 127340. Maintenance designee will report findings to 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: NORTHWEST WING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:20 a.m., revealed improper use of a surge suppressor within the first floor Lounge.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the electrical system deficiencies.




 Plan of Correction - To be completed: 08/28/2022

Surge suppressor properly disposed of. Staff re-educated on improper equipment. Maintenance designee will report findings to QAPI.
Initial comments:Name: MAIN BUILDING - Component: 02 - Tag: 0000


Facility ID# 072802
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed June 28-29, 2022, it was determined that Northampton County Home-Gracedale, 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 two story, Type II (222), fire resistive building, with a basement, a basement-level crawl space, penthouse, and an unused attic, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting two of three floors.

Findings include:

1. Observation on June 28, 2022, at 12:55 p.m., revealed the Dietary Building doors required adjustment to fully latch.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the common wall deficiency.



 Plan of Correction - To be completed: 08/28/2022

Dietary doors were repaired to properly latch and close, W/O#127339. Staff to be re-educated on reporting improperly closing or latching doors. Maintenance designee to report at QAPI.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure, affecting two of two floors.

Findings include:

1. Observation on June 28, 2022, at 12:20 p.m., revealed unprotected dietary windows are presently located within the exit stair tower enclosure.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the exit stair tower deficiency.



 Plan of Correction - To be completed: 08/28/2022

Contractor notified to replace non protected windows with protected windows. Time extension necessary due to material availability. W/O#127368. Maintenance designee to report at QAPI.
NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain exit discharge in one location, affecting to of three floors.

Findings include:

1. Observation on June 28, 2022, at 12:55 p.m., revealed the first floor, exit discharge location, located at door fifteen, was uneven, and lacked a hard-packed surface leading to the common way.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the facility failed to maintain the above exit discharge location.






 Plan of Correction - To be completed: 08/28/2022

Construction process initiated. W/O#101814. Maintenance designee to report at QAPI.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting two of three floors.

Findings include:

1. Observation on June 28, 2022, between 12:02 p.m., and 12:42 p.m., revealed the following:

a. 12:02 p.m., the basement-level, Garbage Room door required adjustment to fully latch.
b. 12:42 p.m., the first floor, NE-1 area is presently used as a storage area, and rooms which contain storage lacked self-closing devices.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the hazardous area enclosure deficiencies.



 Plan of Correction - To be completed: 08/28/2022

1.a) Door adjusted to allow proper latching. W/O#127342.
1.b) Items to be stored properly to eliminate the need for closing device. Staff to be re-educated on identifying unlatched doors and storage. Maintenance designee to report at QAPI.
NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0351

Based on observation and interview, it was determined the facility failed to install automatic sprinklers in one location, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:44 a.m., revealed the basement-level, elevator machine room lacked automatic sprinkler protection.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiency.



 Plan of Correction - To be completed: 08/28/2022

Contractor will install sprinkler. W/O#127343. Maintenance designee to report at QAPI.
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 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:40 a.m., revealed carts were within eighteen inches of an adjacent sprinkle head assembly within the basement-level, Central Storage Two.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiency.



 Plan of Correction - To be completed: 08/28/2022

a) Inspection performed on 4/1/2022.
b) JCI
c) 500,000 Gallon Water Tower supplied by PA American Water
1. Carts were removed and stored properly. Staff to be re-educated on proper storage. Maintenance designee to report at QAPI.
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 - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain one portable fire extinguisher, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 11:48 a.m., revealed the portable fire extinguisher, located at the loading dock, was installed in excess of sixty inches from floor to handle.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the fire extinguisher deficiency.



 Plan of Correction - To be completed: 08/28/2022

Fire extinguisher was remounted below 60 inches. W/O#127344. Maintenance designee to report at QAPI.
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: MAIN BUILDING - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, between 12:10 p.m., and 12:55 p.m., revealed the following following doors lacked smoke-tight integrity:

a. 12:10 p.m., Dietary.
b. 12:53 p.m., NE1-11.
c. 12:55 p.m., NE1-4.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 08/28/2022

1. a,b,c) Doors will be repaired or replaced. W/O#127347. Staff re-educated to identify proper latching. Maintenance designee to report at QAPI.
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 - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain maintain the electrical system in one location, affecting one of three floors.

Findings include:

1. Observation on June 28, 2022, at 12:02 p.m., revealed errant BX wiring was located within the Main Storage Room, at the basement level (located at ceiling level).

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the electrical systems deficiency.



 Plan of Correction - To be completed: 08/28/2022

BX wire to be secured properly. W/O#127346. Maintenance designee to report at QAPI.
Initial comments:Name: TOWER BUILDING - Component: 03 - Tag: 0000


Facility ID# 072802
Component 03
Building 03
Tower Building

Based on a Medicare/Medicaid Recertification Survey completed June 28-29, 2022, it was determined that Northampton County Home-Gracedale, 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 ten story, Type II (222), fire resistive building, with miscellaneous rooftop mechanical spaces, and a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of eleven floors.

Findings include:

1. Observation on June 29, 2022, at 9:33 a.m., revealed the basement-level, Mechanical Room doors were held open by unapproved means.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the the hazardous area enclosure deficiency.




 Plan of Correction - To be completed: 08/28/2022

Doors were properly closed and unapproved means was removed. Staff to be re-educated on identifying door props and properly closed and latching doors. Maintenance designee to report at QAPI.
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: TOWER BUILDING - Component: 03 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting one of eleven floors.

Findings include:

1. Observation on June 29, 2022, at 10:12 a.m., revealed a ceiling tile lacking within the first floor, EMP Room.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiency.




 Plan of Correction - To be completed: 08/28/2022

a. Quarterly sprinkler test was performed on 4/1/2022.
b. JCI
c. Water source is 500,000 water tank supplied by PA American Water.
1. Ceiling tile was replaced. Staff to be re-educated on replacing ceiling tiles. Maintenance Designee to report at QAPI.
NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: TOWER BUILDING - Component: 03 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of eleven floors.

Findings include:

1. Observation on June 29, 2022, at 10:42 a.m., revealed the cigarette butts were located within a trash receptacle, within the outdoor smoking area.

Exit interview with the Facility Administrator and Facilities Manager on June 29, 2022, between 11:00 a.m. and 11:30 a.m., confirmed the smoking regulations deficiency.



 Plan of Correction - To be completed: 08/28/2022

Trash was disposed of properly. Residents and Staff to be re-educated about proper butt disposal. Butt can to be provided. Maintenance designee will report at QAPI.

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