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

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SPRINGFIELD REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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SPRINGFIELD REHABILITATION AND HEALTHCARE 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 conducted on May 30, 2024, at Springfield Rehabilitation And Healthcare 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 #080402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 30, 2024, it was determined that Springfield Rehabilitation And Healthcare Center 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 one-story, Type III (200), unprotected ordinary building, with two partial basements, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
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 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of two levels.

Findings include:

Observation on May 30, 2024, at 11:40 a.m., revealed temporary emergency exit egress path was obstructed by a large fence panel and a barrel, along the path to the public way.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the obstructed egress path.




 Plan of Correction - To be completed: 06/25/2024

This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report.
1. The emergency egress path was immediately cleared of blockage.
2. Compliance to this will be monitored by conducting weekly audits of like areas for 4 weeks then monthly for 2 months to ensure that emergency egress pathways are not blocked. Results will be reported to QAPI with subsequent follow up as needed.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to ensure the protection of exit stairways, affecting one of seven smoke compartments.

Findings include:

Document review and observation on May 30, 2024, at 9:30 a.m., revealed the select care/east wing basement storage room door opened directly into the exit stairway.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the storage room opened into the exit stairway.




 Plan of Correction - To be completed: 06/25/2024

1. Continue with FSES while the center awaits completion of renovations. Renovations approved for completion by Pennsylvania Department of Health, Division of Safety Inspection. Approval Number: H-22-0101"

NFPA 101 STANDARD Number of Exits - Story and Compartment: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.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide not less than two exits remote from one another, affecting two of seven smoke compartments within the facility.

Findings include:

Document review and observation on May 30, 2024, at 9:30 a.m., revealed Central Wing, basement, and the select care/east wing basements, lacked two acceptable fire exits remote from each other.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the facility lacked two exits remote from each other.






 Plan of Correction - To be completed: 06/25/2024

1. Continue with FSES while the center awaits completion of renovations. Renovations approved for completion by Pennsylvania Department of Health, Division of Safety Inspection. Approval Number: H-22-0101"

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 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of two levels.

Findings include:

Observation on May 30, 2024, revealed sprinklers missing escutcheons in the following locations:

a. 11:20 a.m., on the first floor North Nurses Station.
b. 11:40 a.m., on the first floor East Soiled Room.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the missing escutcheons.





 Plan of Correction - To be completed: 06/25/2024

1. The sprinklers at the north wing nurses station and in the east wing soiled utility room had the missing escutcheons placed.
2. Facility conducted an audit of all sprinkler heads to ensure that escutcheons were in place.
3. Compliance to this will be monitored by conducting weekly audits of random like areas for 4 weeks then monthly for 2 months to ensure that escutcheons are in place for sprinkler heads. Results will be reported to QAPI with subsequent follow up as needed.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain laundry chutes with a fire resistance rating, affecting one of seven smoke compartments.

Findings include:

Observation made on May 30, 2024, at 11:50 a.m., revealed the basement center wing laundry chute termination room had an unsealed wall penetration behind the door.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the penetration.





 Plan of Correction - To be completed: 06/25/2024

1. The penetration in the fire-rated wall in the basement where the laundry chute is located has been corrected with UL3M fire protection system Sealart CP25WB+
2. Compliance to this will be monitored by conducting weekly audits of random like areas for 4 weeks then monthly audits for 2 months checking for penetrations. Results will be reported to QAPI with subsequent follow up as needed.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas, affecting one of two levels.

Findings include:

1. Observation on May 30, 2024, at 9:15 a.m., revealed the designated smokers' patio lacked a metal container with a self-closing cover into which ashtrays can be emptied

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the missing ash containers.


2. Observation on May 30, 2024, at 11:05 a.m., revealed the designated Employee Smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area and not in the provided ash receptacles.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 1:15 p.m., confirmed the deficiency.





 Plan of Correction - To be completed: 06/25/2024

1. Smoking receptacles on designated smoking patio were replaced. Cigarette butts in smoking area were cleaned up from grounds.
2. Compliance to this will be monitored by conducting audits of smoking areas weekly for 4 weeks then monthly for 2 months to ensure that proper smoking receptacles are in place and that cigarette butts are not on the ground. Results will be reported to QAPI for subsequent follow up as needed.


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