Pennsylvania Department of Health
CASSELMAN HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CASSELMAN HEALTHCARE AND 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 August 7, 2024, it was determined that Casselman Healthcare and Rehabilitation had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

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.

§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..

Observations:
Name: - Component: -- - Tag: 0041

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on August 7, 2024, at 12:30 p.m., revealed the following emergency generator testing/inspection deficiencies:

a) The facility lacked documentation to confirm if the emergency generator met the annual requirement for no evidence of wet stacking in the last twelve months. The most recent inspection report available was for November 2, 2022;
b) the facility failed to perform the required annual fuel quality testing in the past twelve months. The most recent annual fuel quality inspection was performed on April 3, 2023.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed emergency generator testing /inspection deficiencies.

Plan of Correction - To be completed: 09/17/2024

Contract signed with vendor for completion of wet stacking inspection.
The Nursing Home Administrator re-educated the maintenance director of the need to ensure wet stacking inspections are completed on time. Contract signed with vendor to complete the annual fuel quality testing. Nursing Home Administrator re-educated the maintenance director of the need to ensure the annual fuel quality testing is completed on time. Copies of the inspection reports will be kept in a life safety binder. The maintenance director will review upcoming due dates of inspections at the monthly safety committee meeting for compliance.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID # 136802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 7, 2024, it was determined that Casselman Healthcare and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Vertical Openings - 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.

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, it was determined the facility failed to maintain vertical opening enclosures in three instances, affecting three of seven smoke compartments.

Findings include:

1. Observation on August 7, 2024, revealed the following vertical opening enclosure deficiencies:

a) 10:00 a.m., observation above the ceiling in the west stairwell on the basement level, revealed an unsealed sprinkler pipe penetration in the concrete wall above the heating unit by the outside exit door;
b) 10:27 a.m., observation above the ceiling at the second-floor elevator doors, revealed the elevator wall was not sealed to the deck above;
c) 10:29 a.m., observation above the ceiling at the west stairwell doors on the second-floor, revealed the stairwell wall was not sealed to the deck above.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed vertical opening enclosure deficiencies.

Plan of Correction - To be completed: 09/17/2024

The ceiling in the west stairwell on the basement level revealed an unsealed sprinkler pipe penetration in the concreate wall above the heating unit by the outside exit door. The penetration was sealed. Above the ceiling on the second-floor elevator doors revealed the elevator wall was not sealed to the deck above. The wall was sealed.
Above the ceiling at the west stairwell doors on the second- floor revealed the stairwell was not sealed to the deck above. The stairwell wall was sealed.
The Nursing Home Administrator re-educated the maintenance director and maintenance assistant on need to ensure all vertical openings are sealed.
Vertical openings will be added to the monthly ceiling inspections conducted by the maintenance department to ensure compliance and any areas noted needing sealed or re-sealed will be fixed at time of inspection.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on August 7, 2024, at 10:10 a.m., revealed the facility failed to maintain the required one-hour fire rating in hazardous area enclosures. The door to the soiled linen side of the laundry room was unable to self-close and latch in its frame when tested.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed hazardous are enclosure deficiency.

Plan of Correction - To be completed: 09/17/2024

The door to the soiled linen side of the laundry room was unable to self-close and latch in its frame when tested. The door was adjusted to ensure proper latching.
The Nursing Home Administrator re-educated the maintenance director and maintenance assistant on the need to ensure all doors to hazardous areas latch properly.
Hazardous area door closures will be added to routine maintenance monthly checks in TELS (electronic tracking work order system) to ensure door closures are working correctly to ensure continued compliance. Reports will be submitted to safety 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

Plan of Correction - To be completed: 09/17/2024

The basement housekeeping supervisor/office location had items moved to ensure items are below the 18-inch horizontal sprinkler plane.
The Nursing Home Administrator re-educated the Housekeeping Supervisor and Maintenance Director on the need to ensure all storage rooms are routinely inspected to ensure all items are below the 18-inch horizontal sprinkler plane.
Tape will be used on the walls to provide a visual for staff to easily identify the maximum height that items can be stored. Storage room inspections will be conducted daily x5 days (m-f) times two weeks then random thereafter.
The unsealed penetration beside the sprinkler head escutcheon was sealed in the basement mechanical room. The unsealed wire penetration in the west mechanical room on the second floor was sealed. The unsealed pipe penetration in the south storage room was sealed. The sprinkler head escutcheon in the business office storage room was fixed to touch the ceiling. The Nursing Home Administrator re-educated the maintenance director and maintenance assistant on the need to ensure maintain the sprinkler system to include 18-inch horizontal sprinkler plane and need to maintain a smoke/heat resistive ceiling and to ensure all escutcheons are attached to the ceiling. Visual inspections will be conducted monthly, and tasks added to the TELS electronic work order system. The five-year gauge replacement and internal inspection of the automatic sprinkler system was conducted. The required quarter inspection was conducted by new contracted vendor. The Nursing Home Administrator re-educated the maintenance director on the need to ensure the required sprinkler testing is conducted as required. All inspection reports will be submitted for review by safety committee.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

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

Findings include:

1. Review of documentation on August 7, 2024, at 12:30 p.m., revealed the facility lacked documentation indicating that the individual who conducted the annual fire extinguisher inspection was certified.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed portable fire extinguisher deficiency.

Plan of Correction - To be completed: 09/17/2024

The documentation on file for the qualified person who conducted the annual fire extinguisher testing included suppression but did not include portable fire extinguisher proof. The document will be received by contracted vendor to include portable fire extinguishers. Nursing Home Administrator re-educated the maintenance director on the need to ensure the contracted vendor provided the correct documentation for compliance with testing the fire extinguishers. Documentation will be submitted to safety committee for review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of seven smoke compartments.

Findings include:

1. Observation on August 7, 2024, at 10:51 a.m., revealed multiple unsealed pipe and wire penetrations in the smoke barrier wall, above the ceiling at the south hallway smoke barrier doors, on the second floor.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed smoke barrier wall deficiency.

Plan of Correction - To be completed: 09/17/2024

The multiple unsealed pipe and wire penetrations in the smoke barrier wall above the ceiling at the south hallway smoke barrier doors on second floor were sealed. The Nursing Home Administrator re-educated the maintenance director and maintenance assistant on the need to ensure all pipe and wire penetrations are sealed. Visual inspections will be conducted monthly, and tasks added to the TELS electronic work order system for on-going compliance. Inspection results will be submitted to safety committee for review.

NFPA 101 STANDARD HVAC:

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 documentation review and interview, it was determined the facility failed to ensure smoke dampers were inspected within the required four-year period, affecting six of seven smoke compartments in the facility.

Findings include:

1. Documentation review and interview on August 7, 2024, at 12:30 p.m., revealed the facility failed to perform the required four-year smoke damper inspection. The most recent smoke damper inspection was performed in June 2020.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed smoke damper inspection deficiency.

Plan of Correction - To be completed: 09/17/2024

The four-year smoke damper inspection will be conducted. Nursing Home Administrator re-educated the maintenance director on the need to ensure all required inspections are conducted on time.
Copies of the inspection reports will be kept in a life safety binder. The maintenance director will review upcoming due dates of inspections at the monthly safety committee meeting for on-going compliance.

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills affecting the entire facility.

Findings include:

1. Review of documentation on August 7, 2024, at 12:30 p.m., revealed the facility lacked documentation for a first-quarter fire drill, for the third shift.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed fire drill deficiency.

Plan of Correction - To be completed: 09/17/2024

Three fire drills were conducted in the first quarter, however two first shift drills were conducted instead of a drill on each shift to include the third shift drill. The maintenance director was newly hired and still in probationary period and was being educated on the life safety requirements. All other drills conducted thereafter were in compliance per quarter. The Nursing Home Administrator re-educated the Maintenance director on the need to complete 1 drill per shift per quarter. The maintenance director will review next month's drill at the monthly safety committee for safety committee review to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain electrical receptacles in patient sleeping areas, affecting the entire facility.

Findings include:

1. Documentation review on August 7, 2024, at 12:30 p.m., revealed the facility lacked documentation for an annual inspection of electrical receptacles in patient sleeping rooms, performed in the last twelve months.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed electrical receptacle testing deficiency.

Plan of Correction - To be completed: 09/17/2024

The annual electrical receptacles in patient sleeping rooms was performed however the document was not signed or dated. The maintenance director did not ensure the inspection document was completed as required with date and signature of inspection. The Nursing Home Administrator re-educated the maintenance director and maintenance assistant on the need to ensure that all inspection forms are completed with date and signature. Annual receptacle test was re-completed and verified by date and signature. The maintenance director will bring inspection reports to monthly safety committee for review to ensure compliance.

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 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on August 7, 2024, at 12:30 p.m., revealed the following emergency generator testing/inspection deficiencies:

a) The facility lacked documentation to confirm if the emergency generator met the annual requirement for no evidence of wet stacking in the last twelve months. The most recent inspection report available was for November 2, 2022.;
b) the facility failed to perform the required annual fuel quality testing in the past twelve months. The most recent annual fuel quality inspection was performed on April 3, 2023.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on August 7, 2024, at 2:00 p.m., confirmed the listed emergency generator testing /inspection deficiencies.

Plan of Correction - To be completed: 09/17/2024

Contract signed with vendor for completion of wet stacking inspection.
The Nursing Home Administrator re-educated the maintenance director of the need to ensure wet stacking inspections are completed on time. Contract signed with vendor to complete the annual fuel quality testing. The Nursing Home Administrator re-educated the maintenance director of the need to ensure the annual fuel quality testing is completed on time. Copies of the inspection reports will be kept in a life safety binder. The maintenance director will review the upcoming due dates of inspections at the monthly safety committee meeting for on-going compliance.

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