Pennsylvania Department of Health
PENN HIGHLANDS JEFFERSON MANOR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PENN HIGHLANDS JEFFERSON MANOR
Inspection Results For:

There are  46 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.
PENN HIGHLANDS JEFFERSON MANOR - 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 January 23, 2024, at Penn Highlands Jefferson Manor, 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 #100802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2024, it was determined that Penn Highlands Jefferson Manor was not in compliance with 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress Requirements - 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.
Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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.
18.2, 19.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200

Based on observation and interview, the facility failed to maintain evacuation diagrams on three of three levels.

Findings include:

Observation on January 23, 2024, between 9:46 a.m. and 11:59 a.m., revealed the evacuation diagrams did not contain a notation showing the location of the viewer on the diagram.

Ref: NFPA 170-11.2.4 and 11.3.2

Interview with the maintenance technician on January 23, 2024, at 11:59 a.m., confirmed the above deficiency existed.







 Plan of Correction - To be completed: 02/09/2024

Maintenance Director will add a notation to the evacuation diagrams to indicate the location of the viewer in relation to the diagram. The diagrams are framed and behind glass so once the diagrams are updated they will not change.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, the facility failed to maintain vertical openings for one of one waste chute intake door.

Findings include:

Observation on January 23, 2024, 10:26 a.m., revealed the waste chute intake door failed to latch in the frame.

Interview with the maintenance supervisor on January 23, 2024, 10:26 a.m., confirmed the above deficiency existed.







 Plan of Correction - To be completed: 02/01/2024

The trash chute intake door latch that did not latch was repaired on 1/23/2024. Weekly audits x 4 weeks will be conducted by the Maintenance Director or designee and results reported to the Qualtiy Assurance Process Improvement committee.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, the facility failed to maintain smoke barrier walls to resist the passage of smoke on one of three building levels.

Findings include:

Observation on January 23, 2024, at 10:33 a.m., revealed two drywall patches, measuring approximately 12" x 12", were not taped or sealed along with other smaller penetrations throughout the area that would allow the passage of smoke.

Interview with the maintenance technician on January 23, 2024, at 10:33 a.m., confirmed the above deficiencies existed.








 Plan of Correction - To be completed: 02/09/2024

Maintenance Director will fill in the penetrations in the drywall patches with a UL approved penetration fire stop system. Education and training pertaining to penetrations in rated walls will be conducted with maintenance staff. Maintenance Director will inspect new drywall work each time it is completed by staff x 3 months to ensure no additional areas need to be repaired. Results will be reported to the Quality Assurance Performance Improvement committee.
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting one of three levels.

Findings include:

Document review on January 23, 2024, at 9:56 a.m., revealed the fire system inspection report (dated December 5, 2023) listed one fire/smoke damper deficiency. The report stated that the damper actuator needed replaced.

Interview with the maintenance supervisor on January 23, 2024, at 9:56 a.m., confirmed the deficiency at time of the survey.





 Plan of Correction - To be completed: 02/09/2024

The fire/smoke damper was repaired on 1/29/2024. Smoke dampers will be inspected quarterly to ensure proper operative stability and replaced as necessary. Reports will be presented to the Quality Assurance Process Improvement committee.
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, the facility failed to maintain electrical receptacles, per NFPA 70, in five of over fifty rooms.

Finding include:

Based on observation on January 23, 2024, between 9:46 a.m. and 11:59 a.m., the facility could not verify that ground fault circuit interrupter (GFCI) receptacles were installed near the water sources at the following locations:
A.) (9:46 a.m.) Third floor, SCU pantry;
B.) (10:07 a.m.) Third floor, laundry room;
C.) (10:38 a.m.) Third floor, suites laundry room;
D.) (11:07 a.m.) Second floor, staff lounge bathroom;
E.) (11:59 a.m.) First floor, men's bathroom, admin area.

Interview with the maintenance technician on January 23, 2024, at 11:59 a.m., confirmed the receptacle deficiencies.







 Plan of Correction - To be completed: 02/29/2024

GFCI's will be installed by the Maintenance Director near the 5 identified water sources. Maintenance Director or designee will conduct an audit of all applicable areas and identify other possible required upgrades of existing receptacles. Audits will be conducted on an annual basis and results reported to the Quality Assurance Process Improvment committee.
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 document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator.

Findings include:

Document review on January 23, 2024, at 10:30 a.m., revealed the facility failed to provide a completed fuel quality test report from the previous twelve months.

Interview with the maintenance supervisor on January 23, 2024, at 10:30 a.m., confirmed the diesel fuel test was unavailable at the time of the survey.




 Plan of Correction - To be completed: 02/29/2024

A new, more reliable generator company has been contracted to take the generator fuel sample. Lab results are guaranteed in fewer than 5 business days. It will be completed by 2/29/2024. results will be reported to the Quality Assurance Process Improvement committee.

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