Nursing Investigation Results -

Pennsylvania Department of Health
KINKORA PYTHIAN HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KINKORA PYTHIAN HOME
Inspection Results For:
There are 30 surveys for this facility. Please select a date to view the survey results.

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KINKORA PYTHIAN HOME - 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 June 6, 2022, at Kinkora Pythian Home, 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 #110902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 6, 2022, it was determined that Kinkora Pythian Home 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 noncombustible structure, with a partial basement, which 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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain rated hazardous area doors, to be within the allowed gap margins, affecting one of four smoke compartments within the component.

Findings Include

1. Observation on June 6, 2022, between 12:35 PM and 12:40 PM, revealed various doors had a gap, exceeding 1/8th of an inch, at the following locations:

a. 12:35 PM, Kitchen, Janitor's Closet, top and latch side;
b. 12:40 PM, Kitchen, Food Storage Closet, top and latch side.

Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed the rated doors exceeded the allowable gap margin.

Plan of Correction - To be completed: 07/11/2022

Crown 48 inch top protectors were ordered and will be installed on Janitor Closet door and Kitchen Food Storage Closet. Maintenance Department will perform quarterly audits of doors to assure they are in compliance. Results of audit will be reported quarterly to the Quality Assurance Committee for review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 document review, observation and interview, it was determined the facility failed to maintain the sprinkler piping system, to be free of extraneous weight, failed to provide 5-year maintenance and testing documentation, and failed to maintain the automatic sprinkler system free from obstruction, affecting the entire component.

Findings include:

1. Observation on June 6, 2022, between 12:10 PM and 12:20 PM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 12:10 PM, above smoke door, to South Wing by Restroom, coat hanger wire wrapped around sprinkler;
b. 12:20 PM, above ceiling, Nurses' Station by Soiled Linen Closet, various cable wires tied to sprinkler piping system.

Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed there were various items attached to the sprinkler pipes.

2. Observation on June 6, 2022, at 12:30 PM, revealed one sprinkler head covered with dust, directly above the dryers, in the Laundry Room duct chase closet.

Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed the obstructed sprinkler head.

3. Review of Documentation and observation on May 9, 2022, between 8:45 AM and 11:30 AM, it was revealed the facility was unable to verify when the sprinkler system internal pipe and internal valve inspections had been performed, within the past five years.

Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed the lack of documentation.

Plan of Correction - To be completed: 07/11/2022

All items will be removed from sprinkler piping system. Quarterly audits will be done by the Maintenance Department for the sprinkler piping system to ensure items are not being supported by the sprinkler piping system.

Quarterly audits will be done by Maintenance Department of all sprinkler heads to ensure that they are free from debris and dust.

Susquehanna Sprinkler Company was called and appointment made for inspection of sprinkler system internal pipe and internal valve will be performed. This inspection will be added to our annual inspection list by the Maintenance Department to ensure that it is scheduled annually going forward.

Results of audit will be reported quarterly to the Quality Assurance Committee for review.

NFPA 101 STANDARD Electrical Systems - Receptacles:

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 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles to be Ground Fault Interruption (GFI) protected, within six feet of a water source, in one of six smoke zones within the component.

Findings include:

1. Observation on June 6, 2022, at 12:25 PM, revealed a receptacle, located in sink area at the Nurses' Station, was not GFI protected and within six feet of a water source.

Interview at the time of the exit conference with the Maintenance Director and Administrator on June 6, 2022, at 2:15 PM, confirmed the outlet was not GFI protected.

Plan of Correction - To be completed: 07/11/2022

A GFI receptacle was purchased and will be installed in sink area at nurses' station.

Annual audit of all outlets close to a water source will be done by the Maintenance Department to ensure that it is GFI protected.

Result of audit will be reported annually to the Quality Assurance Committee for review.

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