Nursing Investigation Results -

Pennsylvania Department of Health
SUSQUEHANNA HEALTH AND WELLNESS CENTER
Building Inspection Results

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SUSQUEHANNA HEALTH AND WELLNESS CENTER
Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

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SUSQUEHANNA HEALTH AND WELLNESS 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 May 9, 2022, at Susquehanna Health and Wellness Center 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 #084802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 9, 2022, it was determined that Susquehanna Health and Wellness Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review, observation and interview, it was determined the facility failed to inspect the cooking fire equipment protection system, semi-annually, in one of one smoke zone within the component.

Findings include:

1. Review of documentation and observation on May 9, 2022, between 8:15 AM and 11:45 AM, revealed the kitchen suppression system was not being maintained and inspected, on a semi-annual basis. The inspection and maintenance was conducted on March 2, 2022, only.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the lack of documentation.




 Plan of Correction - To be completed: 06/06/2022

The facility has been scheduled for a full inspection on June 6, 2022 of the kitchen suppression system. Subsequent inspections will be maintained on a semi-annual basis according to the NFPA 101 Cooking Facilities code.

The Maintenance Director will maintain the proper documentation of such inspections on a semi-annual basis.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 provide semi-annual inspections of the fire alarm system, which serves the entire component.

Findings include:

1. Review of documentation on May 9, 2022, between 8:15 AM and 11:45 AM, revealed the facility failed to provide documentation of the semi-annual inspection, due in 3rd quarter of 2021.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the facility could not provide documentation, as to whether the semi-annual visual inspection was done.



 Plan of Correction - To be completed: 06/15/2022


The facility has been scheduled for a full inspection on June 6, 2022 of the kitchen suppression system. Subsequent inspections will be maintained on a semi-annual basis according to the NFPA 101 Alarm System code.

The Maintenance Director will maintain proper documentation of such inspections on a semi-annual basis.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide 5-year maintenance and testing documentation for sprinkler gauges and sprinkler system testing, which serves the entire component.

Findings include:

1. Review of documentation and observation on May 9, 2022, between 8:15 AM and 11:45 AM, it was revealed the facility was unable to verify when the sprinkler gauges had been replaced or recalibrated, within the past five years.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the lack of documentation.

2. Review of documentation and observation on May 9, 2022, between 8:15 AM and 11:45 AM, revealed the facility lacked documentation, verifying the sprinkler system had been inspected, during the 3rd and 4th quarter of 2021.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the lack of documentation, as to whether quarterly inspections were done.



 Plan of Correction - To be completed: 06/15/2022


The facility has been scheduled for a full inspection and/or with a replacement or recalibration of the sprinkler gauges on June 6, 2022. A full inspection of the sprinkler system will be completed that same day as well.

The Maintenance Director will maintain the proper documentation of such inspections on a quarterly basis.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371
Based on observation and interview, it was determined the facility failed to provide at least two smoke compartments on every sleeping floor, with 30 or more patient beds, affecting the entire component.

Findings include:

1. Observation on May 9, 2022, between 8:15 AM and 12:45 PM, revealed the facility lacked smoke barrier walls.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed there were no smoke barrier walls.



 Plan of Correction - To be completed: 06/15/2022


The facility requests DSI to conduct an FSES survey.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 maintain emergency generator signage, affecting the entire component.

Findings include:

1. Observation on May 9, 2022, at 9:35 AM, revealed the remote manual stop station, for the emergency generator, lacked identifying signage.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the lack of emergency generator stop station signage.




 Plan of Correction - To be completed: 06/15/2022

Proper signage identifying the Emergency Generator Stop Station has been put in place.

The Maintenance Director or designee will review placement of signage to ensure proper identification of equipment stop station.

Review will be completed on a weekly basis for 3 weeks, then once a month for 2 months then quarterly.

Reviews will be reported to Qapi each quarter.
NFPA 101 STANDARD Features of Fire Protection - Other: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.
Features of Fire Protection - Other
List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection 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 15 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0932

Based on observation and interview, it was determined the facility failed to maintain Fire Department Connection signage, affecting the entire component.

Findings include:

1. Observation on May 9, 2022, at 10:45 AM, revealed the Fire Department Connection, for the installed sprinkler system, lacked identifying signage.

Interview at the time of the exit conference with the Director of Maintenance, Assistant Director of Nursing and Assistant Maintenance Director on May 9, 2022, at 1:45 PM, confirmed the lack of Fire Department Connection Signage.




 Plan of Correction - To be completed: 06/15/2022

Proper signage identifying the Fire Department Connection signage has been put in place.

The Maintenance Director or designee will review placement of signage to ensure proper identification of the Fire Department Connection.

Review will be completed on a weekly basis for 3 weeks, then once a month for 2 months then quarterly.

Reviews will be reported to Qapi each quarter.

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