Nursing Investigation Results -

Pennsylvania Department of Health
HAMILTON ARMS CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HAMILTON ARMS CENTER
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

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HAMILTON ARMS 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 February 13, 2020, at Hamilton Arms 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 - Component: 01 - Tag: 0000


Facility ID # 080202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 13, 2020, it was determined that Hamilton Arms 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 two-story, Type III, (200), unprotected ordinary structure, with a basement, which 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: MAIN BUILDING - Component: 01 - Tag: 0161

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

Findings include:

1. Observation on February 13, 2020, between 10: AM and 2:00 PM revealed the component is a two-story, Type III (200), unprotected ordinary structure, with a basement, which is fully sprinklered. This facility exceeds the maximum allowable story height for this type of construction.

Interview with the Director of Maintenance on February 13, 2020, at 2:00 PM confirmed the building construction type was not allowed.



 Plan of Correction - To be completed: 03/09/2020

Facility requests a requests an FSES be conducted
NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access to be readily accessible at all times, on one of three floors within the component.

Findings include:

1. Observation on February 13, 2020, at 1:00 PM revealed the doors to the Clean Linen Room, on the ground level, measured 26 inches in width.

Interview with the Director of Maintenance on February 13, 2020, at 1:00 PM confirmed the door did not meet the minimum requirements.


 Plan of Correction - To be completed: 03/09/2020

Facility requests an FSES be conducted
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: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be in good repair, and within the allowed gap margins, on two of three stairtowers within the component.

Findings include:

1. Observation on February 13, 2020, at 1:40 PM revealed the 2nd floor stairtower door, by Resident Room 206, had holes from old hardware.

Interview with the Director of Maintenance on February 13, 2020, at 1:40 PM confirmed the stairtower door had penetrations.

2. Observation on February 13, 2020, at 1:50 PM revealed the ground floor Lobby stairtower door had a gap along the top, greater than 3/16 inch.

Interview with the Director of Maintenance on February 13, 2020, at 1:50 PM confirmed the stairtower door exceeded the allowed gap margins.



 Plan of Correction - To be completed: 04/13/2020

1. The stair tower door at 206 had the penetrations filled with Pemko Siliconseal Adhesive Gasketing and steel fasteners

2.The lobby stair tower door, with gap at the top, caused by the door closure will have the door closure adjusted. The gap at the top of the fire door will be repaired using a U.L. rated material approved for fire doors. Pemko Siliconseal Adhesive Gasketing was the product used

All corridor and stair tower doors will continue to be monitored on a monthly basis. If repairs or corrections are needed they will continue to be performed in an expedient manner.
Maintenance Director will be responsible for monitoring.
Review of the monitoring of the corridor/fire doors is presented to both the safety committee and the Quality Improvement Committee monthly.
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: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the hazardous area doors to be within the allowed gap margins, on one of three floors within the component.

Findings include:

1. Observation on February 13, 2020, at 2:00 PM revealed the ground floor Mechanical Room doors had a gap greater than 3/16 inch, across the top.

Interview with the Director of Maintenance on February 13, 2020, at 2:00 PM confirmed the the hazardous area door exceeded the allowed gap margins.



 Plan of Correction - To be completed: 04/13/2020

The gap at the top of the mechanical/boiler door will be repaired using a UL rated material approved for fire doors. Pemko Siliconseal Adhesive Gasketing was the product used which is approved for fire rated doors
All corridor and fire doors are monitored on a monthly basis.
This process is monitored by the Maintenance Director.
Results of the monitoring are presented to both the Safety Committee and the Quality Improvement Committee on a monthly basis
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to ensure the fire alarm system was being maintained, affecting three of three floors within the component.

Findings include:

1. Document review on February 13, 2020, at 10:30 AM revealed the smoke detector at the top of the elevator shaft had not had an annual functional test in the last two years, per Johnson Control reports.

Interview with the Director of Maintenance on February 13, 2020, at 10:30 AM confirmed the smoke detector had not been tested.



 Plan of Correction - To be completed: 04/13/2020

The smoke detector inside the lobby elevator shaft will be inspected by Johnson Controls on April 4th.
Maintenance Director will monitor Johnson Controls to insure that this is done on their semi-annual inspections.
The results of this monitoring will be reported to the Safety Committee and the Quality Improvement Committee monthly
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: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to close, and to be free of obstructions, on two of three floors within the component.

Findings include:

1. Observation on February 13, 2020, at 12:20 PM revealed first floor Resident Room 164 door was dragging on the threshold, and would not close.

Interview with the Director of Maintenance on February 13, 2020, at 12:20 PM confirmed the door failed to close.


2. Observation on February 13, 2020, at 1:30 PM revealed the 2nd floor Dining Room door, by Resident Room 252, would not close.

Interview with the Director of Maintenance on February 13, 2020, at 1:30 PM confirmed the doors would not close.


3. Observation on February 13, 2020, at 1:45 PM revealed the 2nd floor to Resident Room 205 door was impeded by a wheelchair.

Interview with the Director of Maintenance on February 13, 2020, at 1:45 PM confirmed the door was obstructed from closing.




 Plan of Correction - To be completed: 04/13/2020

1. Resident room door in 164 was adjusted to close and latch.

2. The dining room door on the second floor was adjusted to close and latch

3.The chair/wheelchair was removed from the area in room 205 permitting the door to close and latch

All doors are monitored on a monthly basis. Repairs and corrections are performed in an expedient manner.
Maintenance performs this monitoring on a monthly basis and the results of this are reported to the Safety Committee and Quality Improvement Committee monthly.
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 - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide an emergency stop button, which supplies power to the component.

Findings include:

1. Observations on February 13, 2020, at 12:00 PM revealed the required remote manual stop station, for the generator, outside the generator enclosure. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on February 13, 2020, at 12:00 PM confirmed the switch had not been installed.




 Plan of Correction - To be completed: 04/13/2020

1. An emergency stop button for the emergency generator has been installed.
Maintenance will responsible for checking the stop button on their weekly preventive maintenance check of the generator and
The generator company will be responsible for checking the functioning of the stop button on their inspections


The facility will comply with any of the Life Safety determined requirements.








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