Nursing Investigation Results -

Pennsylvania Department of Health
NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
Building Inspection Results

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NEWPORT MEADOWS HEALTH AND REHABILITATION CENTER
Inspection Results For:

There are  41 surveys for this facility. Please select a date to view the survey results.

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NEWPORT MEADOWS HEALTH 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 January 23, 2020, at Newport Meadows Health 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: 'A' BLDG - Component: 01 - Tag: 0000


Facility ID# 080502
Component 01
"Arbor" Building

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2020, it was determined that Newport Meadows Health And Rehabilitation Center had deficiencies that have the potential for minimal harm as related to 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 V (000), unprotected wood frame 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: 'A' BLDG - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation on January 23, 2020, at 11:00 AM revealed the building is a two-story, unprotected wood frame structure, with a basement, which is fully sprinklered. The building exceeds the maximum allowable story height for this type of construction.

Interview with the Director of Plant Operations on January 23, 2020, at 11:00 AM confirmed the construction type is not allowed in health care.



 Plan of Correction - To be completed: 02/28/2020

Facility requests an FSES evaluation be performed for the A building.
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: 'A' BLDG - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide at least two exits, remote from each other, on each floor or fire section, affecting two of three floors within the component.

Findings include:

1. Observation on January 23, 2020, between 11:00 AM and 11:30 AM, revealed the facility lacked two acceptable means of egress from the 2nd floor, and the basement.

Interview with the Director of Plant Operations on January 23, 2020, at 11:30 AM confirmed the facility failed to provide two exits remote from each other, from each story.





 Plan of Correction - To be completed: 02/28/2020

Facility requests an FSES evaluation be performed for A building.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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: 'A' BLDG - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the rating of vertical openings between floors, affecting one of three floors within the component.

Findings include:

1. Observation on January 23, 2020, at 11:20 AM revealed the attic door, located in the Administration Area, lacked a label indicating the fire resistance rating.

Interview with the Director of Plant Operations on January 23, 2020, at 11:20 AM confirmed the attic door lacked a fire rating label.




 Plan of Correction - To be completed: 02/28/2020

Facility requests an FSES evaluation be performed for A building.
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: 'A' BLDG - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide an emergency shut off, for the generator, affecting three of three floors within the component.

Findings include:

1. Observation on January 23, 2020, at 1:10 PM revealed the generator lacked a remote manual stop station.

Interview with the Director of Plant Operations on January 23, 2020, at 1:10 PM confirmed the lack of a manual emergency shut off.



 Plan of Correction - To be completed: 02/28/2020

Director of Plant Operations contacted Cummins Generator service which services and provides preventative maintenance and repairs to discuss putting an emergency shut off switch on the exterior of the generator. They informed me that they could ship out the part but that I would need an electrician to perform the wiring work. The switch has been ordered as of January 31, 2020 with an estimated arrival date of February 4, 2020. Tommy's Electric service was contacted and will be on site February 3rd, 2020 to provide estimate for work needed. We are awaiting the consultation on February 3, 2020 from the electrician and the shut off part from Cummins Sales and Service.


Initial comments:Name: B & C BLDG - Component: 02 - Tag: 0000


Facility ID #080502
Component 02
"B" and "C" Buildings

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2020, it was determined that Newport Meadows Health 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 three-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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: B & C BLDG - Component: 02 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the smoke detectors to be installed per manufacturer's recommendations, affecting one of three floors within the component.

Findings include:

1. Observation on January 23, 2020, at 12:25 PM revealed the smoke detector within the Elevator Machine Room, in the Staff Lounge, was suspended from a broken mounting bracket by internal wiring.

Interview with the Director of Plant Operations on January 23, 2020, at 12:25 PM confirmed the smoke detector was suspended from internal wiring.




 Plan of Correction - To be completed: 02/28/2020

Director of Plant Operations remounted heat detector on January 24, 2020 at approximately 8am. Detector is active and mounted correctly.
Will monitor detector mounting and functioning properly on monthly facility rounds. Rounds are documented and reported monthly to the facility's QAPI committee.
NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: B & C BLDG - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor doors, affecting one of over 100 corridor doors inspected within the component.

Findings include:

1. Observation on January 23, 2020, at 11:45 AM revealed the undercut of the door, to Resident Room 416, exceeded one inch.

Interview with the Director of Plant Operations on January 23, 2020, at 11:45 AM confirmed the undercut was in excess of the allowable margin.



 Plan of Correction - To be completed: 02/28/2020

Director of Plant Operations contacted a contractor who measured the door on Monday February 3, 2020 to replace the door to room 416. The door is being replaced with a door that lessens the gap to under one inch. The estimated time for the door to arrive is February 25th 2020. All doors will continue to be monitored monthly through a monthly preventative maintenance program in which either the Director of Plant Operations or Designee will complete. Findings will be reported to QA for three months to ensure compliance.
NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: B & C BLDG - Component: 02 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain electrical wiring to be non-ferous, affecting one of three floors within the component.

Findings include:

1. Observation on January 23, 2020, at 11:56 AM revealed approximately eight feet of non-metallic sheathed electrical cable, with a manufacture date of "10DEC2004," located above the suspended ceiling within the Therapy Gym, near the Kitchenette.

Interview with the Director of Plant Operations on January 23, 2020, at 11:56 AM confirmed the use of non-metallic sheathed electrical cable.



 Plan of Correction - To be completed: 02/28/2020

Director of Plant Operations replaced wiring so that it is encased in a metal sheathing on January 24, 2020 at 9:30 am.
The facility will monitor above the ceiling for any unprotected wiring in new installations after a vendor has completed work above the ceiling. The Director of Plant Operations will oversee and inspect projects completed by outside vendors and report inspections to the monthly QAPI committee.
NFPA 101 STANDARD Fire Drills:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: B & C BLDG - Component: 02 - Tag: 0712

Based on document review and interview, it was determined the facility failed to maintain documentation verifying staff participated in fire drills, affecting one of the previous twelve fire drills for the component.

Findings include:

1. Review of documentation on January 23, 2020, between 9:15 AM and 10:45 AM revealed the facility lacked documentation verifying a fire drill had occurred during the 3rd shift since September 11, 2019.

Interview with the Director of Plant Operations on January 23, 2020, at 10:45 AM confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/28/2020

Director of Plant Operations will report all fire drills to the QA committee monthly for the entire year of 2020. Times and shifts will be reviewed to make sure compliance is kept with one per shift per quarter.
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: B & C BLDG - Component: 02 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide an emergency shut off for the generator, affecting three of three floors within the component.

Findings include:

1. Observation on January 23, 2020, at 1:10 PM revealed the generator lacked a remote manual stop station.

Interview with the Director of Plant Operations on January 23, 2020, at 1:10 PM confirmed the lack of a manual emergency shut off.



 Plan of Correction - To be completed: 02/28/2020

Director of Plant Operations contacted Cummins Generator service which services and provides preventative maintenance and repairs to discuss putting an emergency shut off switch on the exterior of the generator. They informed me that they could ship out the part but that I would need an electrician to perform the wiring work. The switch has been ordered as of January 31, 2020 with an estimated arrival date of February 4, 2020. Tommy's Electric service was contacted and will be on site February 3rd, 2020 to provide estimate for work needed. We are awaiting the consultation on February 3, 2020 from the electrician and the shut off part from Cummins Sales and Service.

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