Pennsylvania Department of Health
JULIA POUND CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 45 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.


JULIA POUND CARE 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 July 16, 2024, at Julia Pound Care 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 # 090402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 16, 2024, it was determined that Julia Pound Care 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 II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs for three of over thirty exit signs.

Findings include:

Observation on July 16, 2024, between 11:16 a.m. and 11:38 a.m., revealed the following exit sign deficiencies:
A. (11:16 a.m.) Basement level corridor at the right turn had a missing exit sign;
B. (11:33. a. m.) Main floor corridor entrance to Village House, near resident room 219, had a missing exit sign;
C. (11:38 a.m.) Main floor business area back hallway, had a missing exit sign at the door, near the time clock.

Interview with the maintenance supervisor on July 16, 2024, at 11:38 a.m., confirmed the exit sign deficiencies.

Plan of Correction - To be completed: 08/16/2024

1) An exit sign will be installed in the main corridor at the smoke barrier door leading to the personal care wing.
2) Director of Environmental Services or designee will inspect the installation of the exit sign.
3) Director of Environmental Services or designee will provide education to maintenance staff on the continuity of line of sight for exit signs
4) Following initial installation inspection of the exit sign, will be placed on the monthly inspection sheet of all exit signs. The audits will be on a permanent preventative maintenance schedule, via electronically generated work orders. Results will be reported to QAPI team for further recommendations.

NFPA 101 STANDARD Electrical Systems - Receptacles:

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.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles in one of over twenty rooms.

Findings include:

Observation on July 16, 2024, at 11:04 a.m., revealed the main floor laundry room had no ground fault circuit interrupter (GFCI) protection near the clothes washer.

Interview with the maintenance supervisor on July 16, 2024, at 11:04 a.m., confirmed the electrical outlet deficiency.

Plan of Correction - To be completed: 08/16/2024

1) Personal Care main floor laundry was identified as not having a GFIC protection near the clothes washer. GFIC has been installed on the identified outlet as of 7/20/2019.
2) Director of Environmental services or designee will perform initial audit on all laundry areas for GFIC for all washing machines. To be completed by 8/9/2024.
3) Director of Environmental Services or designee will provide education to all maintenance staff for the proper location of GFIC protection.
4) Any additional needed GFIC will be placed on the monthly inspection sheet of GFIC's. These audits will be on a permanent preventative maintenance schedule, via electronically generated work orders. Results will be reported to the QAPI team for further recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cords in one of over twenty rooms.

Findings include:

Observation on July 16, 2024, at 10:25 a.m., revealed the main floor administration office print room had a refrigerator plugged into a surge protector.

Interview with the maintenance supervisor on July 16, 2024, at 10:25 a.m., confirmed the power cord deficiency.

Plan of Correction - To be completed: 08/16/2024

1) Refrigerator was removed from being plugged in to surge protector on 7/16/2024, this was located in main floor administration off print room.
2) Director of Environmental Services or designee will conduct the initial audit of all office areas to be completed immediately.
3) Director of Environmental Services or designee will provide education to maintenance and office staff On the proper usage of surge protectors.
4) Following the initial inspection, audits will be conducted on office areas monthly for 3 months and then quarterly. These audits will be on a permanent preventative maintenance schedule, via electronically generated work orders. Results will be reported to the QAPI team for further recommendations.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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, the facility failed to maintain gas equipment storage requirements in one of two storage locations.

Findings include:

Observation on July 16, 2024, at 10:59 a.m., revealed the main floor oxygen storage room had unseparated full and empty oxygen cylinders without proper empty/full labeling.

An interview with the maintenance supervisor on July 16, 2024, at 10:59 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 08/16/2024

1) Main floor (personal care oxygen storage room) oxygen tanks were separated between full and empty racks on 7/16/2024. Oxygen storage racks have been labeled to designate full and empty cylinders.
2) Director of Environmental Services or designee will conduct initial audit immediately.
3) Director of Environmental Services or designee will provide education to the Personal Care staff of the proper storage of oxygen tanks.
4) Personal Care Staff will conducted weekly audits of the storage of empty/full oxygen cylinders. Weekly audits will continue for 3 months and then convert to quarterly audits. The results of these audits will be reported to the QAPI team for further recommendations.

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID # 090402
Component 03
Entire Dining Room

Based on a Medicare/Medicaid Recertification Survey completed on July 16, 2024, it was determined that Julia Pound Care 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 Exit Signage:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs in one of over thirty exit signs.

Findings include:

Observation and interview on July 16, 2024, at 10:56 a.m., revealed a missing exit sign in the main floor corridor, at the smoke barrier door leading to the personal care wing.

Interview with the maintenance supervisor on July 16, 2024, at 10:56 a.m., confirmed the exit sign deficiency at the time of the survey.

Plan of Correction - To be completed: 08/16/2024

Exit signs will be installed in the basement level corridor at the right turn, main floor corridor entrance to Village House (near resident room 219), and main floor business area back hallway (near time clock).
2) Director of Environmental Services or designee will inspect the installation of the exit sign.
3) Director of Environmental Services or designee will provide education to maintenance staff on the continuity of line of sight for exit signs
4) Following initial installation inspection of the exit sign, will be placed on the monthly inspection sheet of all exit signs. The audits will be on a permanent preventative maintenance schedule, via electronically generated work orders. Results will be reported to QAPI team for further recommendations.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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: BUILDING 03 - Component: 03 - Tag: 0353

Based on observation and interview, the facility failed to maintain the sprinkler system for two of over fifty sprinkler heads.

Findings include:

Observation on July 16, 2024, at 10:50 a.m., revealed two loose escutcheon plates that created an opening in the ceiling, possibly delaying sprinkler activation, in the dining room storage room.

Interview with the maintenance supervisor on July 16, 2024, at 10:50 a.m., confirmed the above escutcheon plate deficiencies existed.

Plan of Correction - To be completed: 08/16/2024

1) The two loose escutcheon plates in the Personal Care dining room will be repaired to be in accordance to NFPA regulation.
2) Director of Environmental Services or designee will inspected the repair of the 2 sprinkler escutcheon to be in accordance with NFPA regulation.
3) Director of Environmental Services or designee will provide education to maintenance staff on the requirements of the escutcheon place to the ceiling.
4) Following the initial audit of sprinkler escutcheons installed in a fire rated hard ceiling in storage areas, a quarterly inspection will be implemented with the quarterly sprinkler inspection. The audits will be on a permanent preventative maintenance schedule, via electronically generated work orders. Results will be reported to QAPI team for further recommendations.

Initial comments:Name: MEMORY SUPPORT ADDITION - Component: 04 - Tag: 0000

Facility ID # 090402
Component 04
Memory Support/North East Corridor

Based on a Medicare/Medicaid Recertification Survey completed on July 16, 2024, at Julia Pound Care Center, it was determined there were no deficiencies identified under the 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 II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

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