Nursing Investigation Results -

Pennsylvania Department of Health
MISERICORDIA NURSING & REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MISERICORDIA NURSING & REHABILITATION CENTER
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.


MISERICORDIA NURSING & 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 February 10, 2020, at Misericordia Nursing & 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

ID #133302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 10, 2020, it was determined that Misericordia Nursing & 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 structure, with a basement, which 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 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain construction requirements, on three of three floors within the component.

Findings include:

1. Observation on February 10, 2020, between 10:00 AM and 1:00 PM revealed the building is a two-story, Type III (200), unprotected ordinary, fully sprinklered structure. This type of construction is not permitted to be greater than one story.
Interview at the time of the exit conference with the Maintenance Director and Environmental Services Director on February 10, 2020, at 1:00 PM confirmed the construction type was not allowed.

Plan of Correction - To be completed: 03/30/2020

Facility requests an FSES be performed for the building.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

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 stairtower doors to be within allowed gap margins, and to be repaired using a manufacturer approved product, on one of three floors within the component.

Findings include:

1. Observation on February 10, 2020, between 11:00 AM and 11:30 AM, revealed stairtower doors exceeded the allowed gap margins, at the following locations:

a. 11:00 AM, "B" Stairtower door had gaps, greater than 1/8 inch;
b. 11:30 AM, "C" Stairtower door had gaps greater than 1/8 inch;

Interview with the Maintenance Director and Environmental Services Director on February 10, 2020, at 11:30 AM confirmed the stairtower doors exceeded the allowed gap margins.

2. Observation on February 10, 2020, at 12:30 PM revealed "A" Stairtower door had holes from old hardware filled with an unauthorized product.

Interview with the Maintenance Director and Environmental Services Director on February 10, 2020, at 12:30 PM confirmed the door was repaired using an unauthorized product.

Plan of Correction - To be completed: 03/30/2020

Stairtower B & C will be repaired to maintain the allowed gap margins using a manufacturer approved product.

Stairtower A will be repaired with an authorized product.

A monthly door audit will be conducted by the facility maintenance staff to check for allowed gap margins and will make any necessary adjustments/revisions. Also, any holes will be filled with an authorized product.

Findings will be presented quarterly to the QA Committee for further review and evaluation.

The facility alleges substantial compliance by March 30, 2020.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide an emergency stop button for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observations on February 10, 2020, at 10:45 AM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Maintenance Director and Environmental Services Director on February 10, 2020, at 10:45 AM confirmed the switch had not been installed.

Plan of Correction - To be completed: 03/30/2020

Winter Engine - Generator Service will install the required remote manual stop station on the outside of the emergency generator enclosure.

Facility maintenance staff will conduct an annual audit to review for any changes to the emergency generator code and make necessary changes.

Facility alleges substantial compliance by March 30, 2020.

Initial comments:Name: NEW RESIDENT ROOM ADDITION - Component: 02 - Tag: 0000

ID #133302
Component 02
New Resident Room Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 10, 2020, at Misericordia Nursing & Rehabilitation Center, it was determined there were no deficiencies identified under 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 one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: ACITVITIES ROOM ADDITION - Component: 03 - Tag: 0000

ID #133302
Component 03
Activities Room Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 10, 2020, at Misericordia Nursing & Rehabilitation Center, it was determined there were no deficiencies identified under 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 one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

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