Pennsylvania Department of Health
SETON MANOR NURSING AND REHABILITATION CENTER
Building Inspection Results

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SETON MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

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SETON MANOR NURSING 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 April 8, 2024, at Seton Manor Nursing 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 - Component: 01 - Tag: 0000


Facility ID #096902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 8, 2024, it was determined that Seton Manor Nursing 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 structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of doors to exit stairway enclosures, affecting one of eleven smoke compartments within the component.

Findings include:

1. Observation on March 8, 2024, at 11:41 AM, revealed the basement door to the West Stairtower failed to positively latch within the door frame.

Interview with the Director of Maintenance on March 8, 2024, at 11:41 AM, confirmed the door did not latch within the frame.




 Plan of Correction - To be completed: 04/23/2024

West stair tower basement door was adjusted to positively latch within the door frame on 4/8/24.
Maintenance department to be educated on making sure stair way doors positively latch within the door frame.
Audits will be performed by director of maintenance/designee to ensure stair tower doors positively latch weekly x 4 and quarterly x 4. Results to be trended and reported to QAPI committee.


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 observation and interview, it was determined the facility failed to maintain a supply of spare sprinkler heads, affecting the entire component.

Findings include:

1. Observation on March 8, 2024, at 11:36 AM, revealed the facility failed to maintain a supply of concealed pendant sprinkler heads. These heads were observed to be protecting various areas within the component.

Interview with the Director of Maintenance on March 8, 2024, at 11:36 AM, confirmed the lack of spare concealed pendant sprinkler heads.


 Plan of Correction - To be completed: 04/23/2024

Precision Fire was contacted to obtain back up supply of concealed pendant sprinkler head 4/8/24.
Maintenance department to be educated on keeping back up supply of all types of sprinkler heads in stock.
Audits will be performed by director of maintenance/designee to ensure back supply of all types of sprinkler heads weekly x 4 and quarterly x 4. Results to be trended and reported to QAPI committee.

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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance and unobstructed closing of corridor doors, affecting three of eleven smoke compartments within the component.

Findings include:

1. Observation on March 8, 2024, at 11:29 AM, revealed the door to the basement Employee Lounge, across from the Folding Room, failed to positively latch within the door frame.

Interview with the Director of Maintenance on March 8, 2024, at 11:29 AM, confirmed the door did not latch within the frame.


2. Observation on March 8, 2024, at 11:47 AM, revealed the door to the ground floor Sub-Acute Weighing Room was propped open with a wheeled cart, and was unattended.

Interview with the Director of Maintenance on April 8, 2024, at 11:47 AM, confirmed the corridor door was obstructed from closing.


3. Observation on March 8, 2024, at 12:21 PM, revealed the door to the Clean Linen Room, within the 800 Hall, failed to positively latch within the door frame.

Interview with the Director of Maintenance on March 8, 2024, at 12:21 PM, confirmed the door did not latch within the frame.





 Plan of Correction - To be completed: 04/23/2024

Door to employee lounge, and door on 800 hall were adjusted to positively latch withing the door frame on 4/8/24. Cart was removed from sub-acute weighing room so door positively latches withing the door frame.
Nursing staff will be educated on not propping open doors that need to be latched. Maintenance department to be educated on making sure doors positively latch within the door frame.
Audits will be performed by director of maintenance/designee to ensure doors positively latch weekly x 4 and quarterly x 4. Results to be trended and reported to QAPI committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers, affecting one of eleven smoke compartments within the component.

Findings include:

1. Observation on March 8, 2024, at 12:16 PM, revealed a receptacle multiplier was in use in the Rehab Director's Office.

Interview with the Director of Maintenance on March 8, 2024, at 12:16 PM, confirmed the use of a receptacle multiplier.


 Plan of Correction - To be completed: 04/23/2024

The receptacle multiplier was removed from rehab director's office 4/8/24.
The rehab director will be educated on not using non- approved electrical equipment.
Audits will be performed by director of maintenance/designee to ensure no non-approved electrical equipment is used weekly x 4 and quarterly x 4. Results to be trended and reported to QAPI committee.

NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg: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.
Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929

Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of eleven smoke compartments within the component.

Findings include:

1. Observation on March 8, 2024, at 12:02 PM, revealed an unsecured "E" size portable oxygen cylinder located within the 100 Hall Oxygen Room.

Interview with the Director of Maintenance on March 8, 2024, at 12:02 PM, confirmed the portable oxygen cylinder was not secured.



 Plan of Correction - To be completed: 04/23/2024

The unsecured O2 tank was secured in a holder 4/8/24.
Nursing staff to be educated on proper handling of O2 tanks.
Audits will be performed by director of maintenance/designee to ensure no O2 tanks are unsecured weekly x 4 and quarterly x 4. Results to be trended and reported to QAPI committee.


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