Nursing Investigation Results -

Pennsylvania Department of Health
GREENERY CENTER FOR REHAB AND NURSING
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENERY CENTER FOR REHAB AND NURSING
Inspection Results For:

There are  31 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.
GREENERY CENTER FOR REHAB AND NURSING - 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 September 25, 2019, at Greenery Center for Rehab and Nursing, 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# 135602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 25, 2019, it was determined that Greenery Center for Rehab and Nursing 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 non-combustible building, without a basement, that is fully sprinklered.


 Plan of Correction:


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 one instance, in one of five smoke compartments.

Findings include:

1. Observation on September 25, 2019, revealed the following automatic sprinkler system deficiencies:

a) 11:13 a.m., three M.C. cables were laying on the sprinkler pipe above the ceiling near room 308;
b) 11:54 a.m., a wire tied to a sprinkler pipe was supporting the ceiling grid, in the corridor near room 209.

Interview with the Facility Administrator and Maintenance Director on September 25, 2019, at 1:30 p.m., confirmed the automatic sprinkler piping deficiencies.



 Plan of Correction - To be completed: 11/15/2019

The three MC cables laying on the sprinkler pipe above the ceiling near room 308 has been removed from the sprinkler pipe. The wired tied to the sprinkler pipe supporting the ceiling grid near room 209 has been removed. The maintenance department will randomly remove 6 ceiling tiles in each hallway to check for cables or wires weekly for one month, then 4 tiles bi-weekly for month. Findings will be reported to the QAPI committee. The QAPI committee will determine the need for continued monitoring.
NFPA 101 STANDARD Corridor - Doors: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.
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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in six instances, for six of more than 75 doors inspected in the facility.

Findings include:

1. Observation on September 25, 2019, revealed the following corridor door deficiencies:

a) 11:04 a.m., the door to resident room 311 would not close and latch when tested;
b) 11:51 a.m., the door to resident room 105 would not close and latch due to being obstructed by a fall mat;
c) 12:35 p.m., the door to the zone four clean linen room across from the south nurse station would not close and latch when tested;
d) 12:41 p.m., the door to resident room 214 would not close and latch when tested;
e) 12:43 p.m., the door to resident room 204 would not close and latch when tested.

Interview with the Facility Administrator and Maintenance Director on September 25, 2019, 1:30 p.m., confirmed the corridor door deficiencies.




 Plan of Correction - To be completed: 11/15/2019

The doors to resident rooms 311, 105, 214, 204, and zone four clean linen room will be adjusted to ensure proper latching. The maintenance department will randomly check 5 doors on each unit weekly for one month, and 5 doors bi-weekly for one month. Doors will be adjusted as needed to ensure proper latching. Results will be reported QAPI committee. The QAPI committee will determine the need for continued monitoring.
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 Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator for one of one generators, affecting the entire facility.

Findings include:

1. Observation on September 25, 2019, at 10:48 a.m., revealed there was no emergency generator remote manual stop station located outside of the room housing the generator.

Interview with Facility Administrator and Maintenance Director on September 25, 2019, at 1:30 p.m., confirmed there was not a remote manual stop switch located outside of the generator room.




 Plan of Correction - To be completed: 11/15/2019

An emergency generator remote manual stop station will be installed outside of the room housing the generator. Work will be done by a contracted service. The maintenance director will report the completion of the remote manual stop station to the QAPI committee.

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