Pennsylvania Department of Health
 SUNSET RIDGE REHABILITATION AND NURSING CENTER
Building Inspection Results

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SUNSET RIDGE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  37 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SUNSET RIDGE REHABILITATION AND NURSING 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 April 08, 2024, at Sunset Ridge Healthcare 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: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 090002
Component 01
Main Building


Based on a Medicare/Medicaid Recertification Survey completed on April 08, 2024, it was determined that Sunset Ridge Healthcare 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 one story, Type V (111), protected, wood-frame building, 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: MAIN BUILDING 01 - 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 smoke compartments.

Findings include:

1. Observation on April 08, 2024, at 11:32 a.m., revealed the Boiler Room door, was not smoke-tight when latched into frame.

Interview at the time of the exit conference with the Facility Administrator and Facilities Director on April 08, 2024, at 12:00 p.m., confirmed the hazardous area enclosure deficiency.








 Plan of Correction - To be completed: 05/01/2024

1.The boiler room door will be repaired to make it smoke tight when latching.
2.The Maintenance Director/Designee will check doors in the facility to ensure they are smoke tight when latching and make repairs as needed.
3.Doors will be randomly audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee.
4.Audits will be reviewed at QAPI for review and recommendation.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to monitor the installation of alcohol base hand rub dispensers (ABHR), affecting one of one floors.

Findings include:

1. Observation on April 08, 2024, between 10:15 a.m., and 11:37 a.m., revealed the following:
a. At 10:15 a.m., West Wing, corridor wall outside resident room 131, ABHR dispenser located less than one inch from an electrical outlet.
b. At 10:20 a.m., West Wing, inside resident room 127, ABHR dispenser located less than one inch from an wall mounted nightlight.
c. At 11:37 a.m., Main Lobby Area, inside Beauty Shop, ABHR dispenser located less than one inch from a light switch.

Interview at the time of the exit conference with the Facility Administrator and Facilities Director on April 08, 2024, at 12:00 p.m., confirmed the ABHRs were installed too close to an ignition source.









 Plan of Correction - To be completed: 05/01/2024

1.The ABHR dispensers in room 131, 127, main lobby area, and inside the beauty shop will be removed away from ignition sources.
2.The Maintenance Director/Designee will check ABHR dispensers to ensure they are away from ignition sources and move as needed.
3.Rooms will be randomly audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee.
4.Audits will be reviewed at QAPI for review and recommendation.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of three smoke compartments.

Findings include:

1. Observation on April 08, 2024, at 11:02 a.m., revealed the East Wing, Dining Room door was not smoke-tight when latched into frame.

Interview at the time of the exit conference with the Facility Administrator and Facilities Director on April 08, 2024, at 12:00 p.m., confirmed the corridor opening deficiency.







 Plan of Correction - To be completed: 05/01/2024

1.The East Wing, Dining Room door will be repaired to make it smoke tight when latching into the frame.
2.The Maintenance Director/Designee will check doors in the facility to ensure they are smoke tight when latching and make repairs as needed.
3.Doors will be randomly audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee.
4.Audits will be reviewed at QAPI for review and recommendation.

NFPA 101 STANDARD Fire Drills: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 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: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform the required quarterly fire drills for staff.

Findings include:

1. Review of documentation on April 08, 2024, between 9:15 a.m., and 10:10 a.m, revealed the facility did not perform a required fire drill for 3rd shift, from July 2023 to September 2023.


Interview at the time of the exit conference with the Facility Administrator and Facilities Director on April 08, 2024, at 12:00 p.m., confirmed this fire drill was not conducted.







 Plan of Correction - To be completed: 05/01/2024

1.Fire Drills will be completed, as required, quarterly on each shift.
2.The Maintenance Director/Designee will conduct the drills.
3.Fire Drills will be audited by the Administrator to ensure compliance.
4.Audits will be reviewed at QAPI for review and recommendation.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain portable oxygen cylinder storage in one of three smoke compartments.

Findings include:
1. Observation on April 08, 2024, at 10:30 a.m., Central Supply, revealed freestanding portable oxygen cylinders being stored in the oxygen storage room.
Interview at the time of the exit conference with the Facility Administrator and Facilities Director on April 08, 2024, at 12:00 p.m., confirmed the oxygen cylinders was not secured from falling over.









 Plan of Correction - To be completed: 05/01/2024

1.The freestanding portable oxygen cylinders were secured.
2.The Maintenance Director/Designee will ensure all portable oxygen cylinders are secured.
3.Portable oxygen will be randomly audited to ensure compliance.
4.Audits will be reviewed at QAPI for review and recommendation.


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