Pennsylvania Department of Health
PETERS TOWNSHIP POST ACUTE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PETERS TOWNSHIP POST ACUTE
Inspection Results For:

There are  39 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.
PETERS TOWNSHIP POST ACUTE - 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 November 25, 2024, at Peters Township Skilled 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 01 - Component: 01 - Tag: 0000

Facility ID# 126302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 25, 2024, it was determined that Peters Township Skilled 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 two-story, Type III (200), unprotected ordinary building, without a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements for the entire building.

Findings include:

1. Observation and interview on November 25, 2024, at 9:10 a.m., revealed the building is a two-story, unprotected ordinary structure, that is fully sprinklered. This type of construction is not permitted to be greater than one story in height.

Interview with the Facility Administrator, Assistant Administrator, and Maintenance Director on November 25, 2023, at 1:30 p.m., confirmed the construction type and height deficiency.






 Plan of Correction - To be completed: 01/01/2025

The FSES was done and is on file with Life safety and the Time Limited Waiver has been submitted.
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, observation, and interview, it was determined the facility failed to maintain the kitchen hoods in two instances, affecting one of five smoke compartments.

Findings include:

1. Document review and observation on November 25, 2024, revealed the following kitchen deficiencies:

a) 9:12 a.m., the facility failed to perform one of the two required semi-annual hood cleanings;
b) 9:18 a.m., facility failed to perform one of the two required semi-annual ansul system inspections.

Interview with the Facility Administrator, Assistant Administrator, and the Maintenance Director on November 25, 2024, at 1:30 p.m., confirmed the above listed deficiencies.



 Plan of Correction - To be completed: 01/01/2025

The services that were scheduled at the beginning of the year was cancelled right before the second semi annual service due to the old parent company refusal of payment. the dates were for March and September. This refusal of payment caused the error to occur. With the new parent company and the payment the service was completed on 12/11/2024.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345


Based on documentation review, observation and interview, it was determined the facility failed to maintain the fire alarm system in one instance, affecting the entire facility.

Findings Include:

1. Review of documentation on November 25, 2024, at 8:50 a.m., revealed the facility lacked documentation of an annual fire alarm system inspection/test.

Interview with the Facility Administrator, Assistant Administrator, and Maintenance Director on November 25, 2024, at 1:30 p.m., confirmed the facility lacked documentation of an annual fire alarm system inspection/test.








 Plan of Correction - To be completed: 01/01/2025

The annual Fire Alarm test/inspection has been scheduled and completed as of December. The Maintenance Director has been educated by the administrator and local regional support to make sure that it is done timely.
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 the facility failed to maintain the automatic sprinkler system in two instances, affecting two of five smoke compartments.

Findings include:

1. Observation on November 25, 2024, revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper operation/activation of the automatic sprinkler system in the following locations:

a) 10:54 a.m., there was a gap in the ceiling tile, greater than 1/8 inch, in the ceiling tile near the Ansul system in the kitchen;
b) 10:56 a.m., there was a gap in the ceiling tile, greater than 1/8 inch, in the Storage room near the elevator on the first floor.

Interview with the Facility Administrator, Assistant Administrator, and the Maintenance Director on November 25, 2024 at 1:30 p.m., confirmed the unsealed ceiling tile penetrations.





 Plan of Correction - To be completed: 01/01/2025

Gaps that were observed have been caulked with Red Fire Caulk in the kitchen to ensure that there are no more cracks. Ceiling was inspected and parts replaced as necessary to fix the problem. Inspections are now in place to see that there are no more cracks, and if needed things can be put into place to fix the problems as they appear.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port