Pennsylvania Department of Health
PAUL'S RUN
Building Inspection Results

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PAUL'S RUN
Inspection Results For:

There are  41 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.
PAUL'S RUN - 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 January 11, 2024, at Paul's Run, 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# 161902
Component 01
Main Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on January 11, 2024, it was determined that Paul's Run was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 II (222), fire resistive building, with a partial basement and an unused attic, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on document review and interview, it was determined the facility failed to ensure exits were readily accessible, affecting two of three floors within the facility.

Findings include:

Document review on January 11, 2024, at 12:00 p.m., revealed Basement, exit access corridor had less than six feet two inches headroom clearance from overhead pipes. The minimum headroom clearance requirement, with obstructions, is six feet eight inches.

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed headroom clearance did not meet the minimum requirement.




 Plan of Correction - To be completed: 02/03/2024

The Fire Safety Evaluation System (FSES) is in place since 2005. We request that DOH conduct an FSES to resolve this deficiency.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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 document review and interview, it was determined the facility failed to ensure vertical openings between floors were enclosed with the required fire resistance rating, affecting two of two floors.

Findings include:

Document review on January 11, 2024, at 8:45 a.m., revealed resident bathroom exhaust shafts lacked required one-hour resistance rating. The shafts walls were constructed of metal studs with single sheets of drywall.

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed the bathroom exhaust shafts were not enclosed properly.





 Plan of Correction - To be completed: 02/03/2024

Shafts are a component of FSFS in place since 2005. Request made to DOH Division of safety inspection to update our FSES to place us in compliance with 2012 Life Safety Code.
Vents are cleaned monthly as part of the preventative maintenance to ensure function. Reviewed by Maintenance Director to ensure compliance.
Dampers are inspected every 4 years by Safecheck Fire Company, last completed 10/2020.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on document review and interview, it was determined the facility failed to ensure smoke compartments do not exceed 22,500 square feet, affecting two of five smoke compartments.

Findings include:

Document review on January 11, 2024, at 8:45 a.m.., revealed the following smoke compartments exceeded the 22,500 square feet maximum allowance:

Zone 1 - Second Floor, Rooms 201-207; 241-247; 225-239 and office area.
Zone 3 - First Floor, Rooms 101-107; 141-147; 125-139, Laundry and Storage Areas.

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed the smoke compartments exceeded the maximum allowance.





 Plan of Correction - To be completed: 02/03/2024

FSES in place since 2005. Request submitted to DOH to update our FSES to place us in compliance with the 2012 FSES Life Safety Code.
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 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 the fire resistance of smoke barriers, affecting one of two levels in the facility.

Findings include:

Observation on January 11, 2024, at 9:49 a.m., revealed, on the second floor, the smoke barrier in the West wing had an open penetration by data wires above the smoke barrier doors.

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed the open penetration.




 Plan of Correction - To be completed: 02/15/2024

Penetrations corrected filled with fire caulk FS-one Max on 1/12/2024. Follow-up will involve the replacement of FS-one Max with UL approved 3M Fire Barrier Sealant CP25WB.
Maintenance Director will follow-up after any new wiring immediately full any penetrations/installation of wiring.
NFPA 101 STANDARD Electrical Systems - Receptacles: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 - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on documentation review and interview, it was determined the facility failed to ensure that electrical receptacles were tested in patient care rooms and at deep sedation bed locations, within the facility.

Findings include:

Document review on January 11, 2024, at 8:45 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed the facility could not provide documentation that the receptacles were tested.






 Plan of Correction - To be completed: 02/29/2024

Maintenance staff have been re-educated on testing/inspection of electrical receptacles in patient care rooms. Testing and inspection of the first 10 resident rooms will begin on 2/1/24 and be completed by 2/29/24. Ten rooms per month will be tested/inspected monthly.
A report will be filed with the community QAPI team on a monthly basis for the next three months beginning with the March, 2024 meeting.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on January 11, 2024, at 8:45 a.m., revealed the facility could not provide documentation of of weekly battery voltage inspection.

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/03/2024

Maintenance Director will create a weekly work order into our maintenance system to automatically notify staff to document the battery inspection. Maintenance Director will monitor completion of work orders during weekly rounds. Findings and corrections will be reported to the QAPI team on a monthly basis.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain gas cylinder and container storage rooms, affecting two of six smoke compartments in the facility.

Findings include:

Observations on January 11, 2024, between 9:57 a.m. and 10:02 a.m., revealed the Oxygen Storage Rooms lack signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." in the following locations:

a. Second floor Oxygen Storage;
b. First floor Oxygen Storage.

Exit interview with the Administrator and the Maintenance Director on January 11, 2024, at 10:15 a.m., confirmed the lack of signage.





 Plan of Correction - To be completed: 01/16/2024

Oxygen Storage room signage for 1st and 2nd floor was corrected/installed on 1/16/24.
Signage will be checked monthly and reported at the QAPI meeting beginning in February for a period of three months and periodically therafter.

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