Nursing Investigation Results -

Pennsylvania Department of Health
MEADOWS NURSING AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MEADOWS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  42 surveys for this facility. Please select a date to view the survey results.

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MEADOWS NURSING 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 November 17, 2021, at Meadows 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# 137302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 17, 2021, it was determined that Meadows 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 three story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


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 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower, affecting three of three floors.

Findings include:

1. Observation on November 17, 2021, at 10:55 a.m., revealed the administration stair tower enclosure lacked required, one-hour, fire resistive integrity due to a recessed heating unit, located within the stair tower wall at the first floor level.

Exit interview with the Facilities Manager on November 17, 2021, between 11:00 a.m. and 11:56 a.m., confirmed the stair tower enclosure deficiency.




 Plan of Correction - To be completed: 01/15/2022

1. The existing heating unit located in the administration stair tower has been removed and wall sheet rocked and finished, to retain fire rating.
2. Maintenance will control and monitor the installation of wall units to ensure proper fire rating
3. Installation of heating units shall be audited by Maintenance Supervisor/designee and results of audit shall be discussed at QA for comment and review.
4. Corrective Action Date January 15, 2022

NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in one location, affecting one of three floors.

Findings include:

1. Observation on November 17, 2021, at 10:43 a.m., revealed the first floor, exit access corridor system lacked exit signage at the Lobby entrance.

Exit interview with the Facilities Manager on November 17, 2021, between 11:00 a.m. and 11:56 a.m., confirmed the exit signage deficiency.



 Plan of Correction - To be completed: 01/15/2022


1. Facility has contracted a licensed Electrical Contractor to install exit signage at lobby entrance on the first floor.
2. Maintenance will continue to monitor exit signage on a monthly schedule as part of preventative maintenance. Results of audit will be brought to QA Committee for review.
3. Corrective Action Date January 15, 2022

NFPA 101 STANDARD Corridor - Doors: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.
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 one corridor opening, affecting one of three floors.

Findings include:

1. Observation on November 17, 2021, at 9:59 a.m., revealed the third floor, Zone 3-3 Clean utility Room door was not smoke-tight.

Exit interview with the Facilities Manager on November 17, 2021, between 11:00 a.m. and 11:56 a.m., confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 01/15/2022

1. Maintenance has applied Pemco Silicone Seal S77, a High Temperature gasket seal to maintain required smoke parameters for the third floor, Zone 3-3 Clean utility Room door.
2. All Doors have been audited for compliance with NFPA 101 STANDARD
Corridor Doors.
3. Maintenance Door inspections will continue with documentation as part of the preventative maintenance program. Findings shall be reported to QA committee for review and recommendations.
4. Corrective Action Date January 15, 2022

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier doors, affecting one of three floors.

Findings include:

1. Observation on November 17, 2021, at 9:55 a.m., revealed the third floor, Zone 3-3 smoke barrier separation doors did not fully latch.

Exit interview with the Facilities Manager on November 17, 2021, between 11:00 a.m. and 11:56 a.m., confirmed the smoke barrier separation door deficiency.




 Plan of Correction - To be completed: 01/15/2022

1. Adjustments have been made to door closure revealed on the third floor, Zone 3-3 to confirm full/positive latching.
2. Smoke Barrier Doors have been audited for positive latching.
3. Maintenance door inspection shall continue and be documented as part of the preventative maintenance program. Result of findings shall be brought to QA Committed for review and recommendations.
4. Corrective Action Date January 15, 2022


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