Nursing Investigation Results -

Pennsylvania Department of Health
NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC
Inspection Results For:

There are  25 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.
NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC - 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 September 19, 2019, at North Strabane Rehabilitation and Wellness Center, LLC, 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# 09220200
Component 01
Skilled Nursing Building

Based on a Medicare/Medicaid Recertification Survey completed on September 19, 2019, it was determined that North Strabane Rehabilitation and Wellness Center, LLC, 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, without a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on documentation review, observation and interview, it was determined the facility failed to maintain carbon monoxide alarms, per the manufacturer requirements, as required by the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

1. Documentation review, on September 19, 2019, at 11:06 a.m., revealed the facility failed to provide documentation showing the completion of the monthly inspection and testing of battery powered carbon monoxide alarms.

Interview with the Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the lack of documentation at the time of survey.








 Plan of Correction - To be completed: 10/24/2019

A house audit was performed to ensure proper functioning of battery powered carbon monoxide alarms.
The Dir. of Maintenance was educated on the requirements of monthly inspection and testing of battery powered carbon monoxide alarms.
The Dir. of maintenance or designee will perform audits of the carbon monoxide alarms monthly per the regulation.
NFPA 101 STANDARD Cooking Facilities: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.
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 01 - Component: 01 - Tag: 0324

Based on documentation review, it was determined that the facility failed to maintain the kitchen suppression system in one instance, affecting one out of four smoke compartments.

Findings include:

1. Documentation review on September 19, 2019, at 9:00 a.m., revealed the facility failed to provide documentation showing the correction of deficiencies found at the time of the most recent kitchen suppression system inspected, dated 06/13/2019. The inspection report shows there is not adequate detection above each appliance served by the system, affecting system response and performance.

Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 9:00 a.m., confirmed the existence of the uncorrected deficiencies.




 Plan of Correction - To be completed: 10/24/2019

The identified deficiencies will be corrected by 10/24/19. A house audit was performed to confirm there is adequate detection above each appliance served by the system.
The Dir of maintenance was educated on the requirements to maintain the kitchen suppression system.
Auditing of the system will be done by the Dir. Of maintenance or designee.
NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351
Based on observation and interview, it was determined that the facility failed to maintain installation requirements in four instances, affecting the entire facility.

Findings include:

1. Observation on September 19, 2019, revealed the following exterior locations contained combustible overhangs, greater than four feet, without automatic sprinkler protection:

a) 9:45 a.m., the kitchen rear exit;
b) 9:50 a.m., the employee smoking area exit;
c) 9:55 a.m., the business office hallway exit;
d) 10:00 a.m., the activities room secondary exit.

Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the lack of automatic sprinkler protection.




 Plan of Correction - To be completed: 10/24/2019

Automatic sprinkler heads will be installed in all identified locations by 10/24/19; the kitchen rear exit, the employee smoking area, the business office hallway exit, the activities room secondary exit.
The Dir of maintenance was educated on NFPA 13, specifically combustible overhangs, greater than four feet, requiring automatic sprinkler protection.
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 that the facility failed to maintain the automatic sprinkler system in four instances, affecting one out of four smoke compartments.

Findings include:

1. Observation on September 19, 2019, revealed the following:

a) 9:40 a.m., there were ten corroded sprinkler heads under the main entrance drive-thru canopy and porch;
b) 11:20 a.m., there were five sprinkler heads missing escutcheons at the main nurses station;
c) 11:22 a.m., there was a sprinkler head with a frangible bulb that was missing its fluid, affecting the responsiveness of the sprinkler system;
d) 11:26 a.m., there was a sprinkler head missing an escutcheon in resident room 108.

Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the sprinkler system deficiencies.




 Plan of Correction - To be completed: 10/24/2019

The ten sprinkler heads underneath the main entrance drive-thru canopy and porch will be replaced by 10/24/19.
The five escutcheons missing at the nurse's station have been replaced.
The sprinkler head that was missing fluid will be filled by 10/24/19.
The sprinkler head that was missing an escutcheon in room 108 has been replaced.
The Dir. of maintenance was educated on timely inspection, testing, and maintaining the fire protection system.
The Director of Maintenance or designee will complete an audit 3 times per week for two weeks, weekly for two weeks, and monthly thereafter to ensure proper fire protection.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined that the facility failed to maintain corridor doors in two instances, affecting two of over one hundred doors inspected.

Findings include:

1. Observation on September 19, 2019, revealed the following:

a) 11:17 a.m., the door to resident room 309 failed to positively latch in its frame when tested;
b) 11:18 a.m., the door to resident room 305 required excessive force to close and positively latch in its frame when tested.

Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the corridor door deficiencies.



 Plan of Correction - To be completed: 10/24/2019

Resident 305 and 309 properly close and latch.

A house audit was conducted to ensure all doors positively latch.

An audit on corridor doors will be completed by the Maintenance Director or designee weekly for four weeks, bi-weekly for two weeks, and monthly thereafter.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on September 19, 2018, at 8:40 a.m., revealed the facility lacked documentation for a fourth quarter fire drill for the second shift.

Interview with the Facility Administrator on September 19, 2019, at 8:40 a.m., confirmed the fire drill documentation was not available at the time of survey.



 Plan of Correction - To be completed: 10/24/2019

The facility was unable to provide documentation showing one of the 12 required fire drills.

The Dir. of Maintenance was educated on record keeping of routine maintenance including fire drill reports.
The Dir. of maintenance shall complete routine fire drills per regulation, and maintain proper documentation in the maintenance office.

The administrator or designee will audit the monthly fire drills to ensure proper documentation and record keeping of monthly fire drills.
NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined that the facility failed to maintain electrical wiring in one instance, affecting one out of four smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 6.3.2.1 NFPA 99.

Findings include:

1. Observation on September 19, 2019, at 11:30 a.m., revealed unterminated wiring, hanging out of the ceiling, in the physical therapy directors office.

Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the electrical wiring deficiency.








 Plan of Correction - To be completed: 10/24/2019

The unterminated wiring in the Therapy Director's office was addressed and sealed up on the day of the survey. The Dir. of Maintenance was educated on exposed wiring in the building.

The Dir. of maintenance completed a house audit to ensure there are no unterminated wires in the facility.

Auditing will be performed by the Dir. of maintenance or designee monthly.
NFPA 101 STANDARD Electrical Systems - Receptacles: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.
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, it was determined that the facility failed to maintain electrical receptacles in one instance, affecting one out of over one-hundred receptacles inspected.

Findings include:

1. Observation on September 19, 2019, at 10:38 a.m., revealed an electrical receptacle, within six feet of a sink that was not GFCI protected, at the 400 hallway nurses station.

Interview with the Facility Administrator and Maintenance Director on September 19, 2019, at 1:45 p.m., confirmed the electrical receptacle deficiency.




 Plan of Correction - To be completed: 10/24/2019

The electrical receptacle near the sink behind the 400 hall nursing station has been replaced, and is now GFCI protected.

The Dir. Of Maintenance completed a house audit to make sure outlets within 6 feet of a sink are GFCI protected.
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 Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator for one of one generators, affecting the entire facility.

Findings include:

1. Observation on September 19, 2019, at 9:50 a.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosure.

Interview with the Facility Administrator and Director of Maintenance on September 19, 2019, at 9:50 a.m., confirmed there was not a remote manual stop switch located outside of the generator enclosure.




 Plan of Correction - To be completed: 10/24/2019

A new emergency generator remote manual stop station will be installed for our generator by 10/24/19.
The Dir. of Maintenance was educated on the requirement pertaining to an emergency generator remote manual stop station for the generator.
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 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on September 19, 2019, at 8:45 a.m., revealed the facility lacked documentation for an annual load bank test for the emergency generator.

Interview with the Facility Administrator on September 19, 2019, at 8:45 a.m., confirmed the facility lacked annual generator testing documentation, at the time of the survey.




 Plan of Correction - To be completed: 10/24/2019

The facility conducted a load bank on 9/25/19.
The Dir. of maintenance was educated on the documentation requirement of the annual load bank test.

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