Pennsylvania Department of Health
PASSAVANT RET & HEALTH CTR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PASSAVANT RET & HEALTH CTR
Inspection Results For:

There are  19 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.
PASSAVANT RET & HEALTH CTR - 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 April 2, 2024, at Passavant Retirement and Health Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: NEW SKILLED NURSING - Component: 03 - Tag: 0000


Facility ID 163602
Component 03
New Skilled Nursing

Based on a Recertification/Relicensure Survey completed on April 2, 2024, it was determined that Passavant Retirement and Health 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 (111), protected, non-combustible building, that is fully sprinklered.




 Plan of Correction:


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: NEW SKILLED NURSING - Component: 03 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs on two of three floors.

Findings include:

Observation on April 2, 2024, between 10:13 a.m. and 10:59 a.m., revealed the following exit sign deficiencies:
A. (10:13 a.m.) Third floor, stairwell 9000 failed to show the exit route from any direction from the stair tower;
B. (10:59 a.m.) Second floor, stairwell 9000 failed to show the exit route from any direction from the stair tower.

Interview with the maintenance director on April 2, 2024, at 10:59 a.m., confirmed the above areas failed to show exit routes from any direction.






 Plan of Correction - To be completed: 05/31/2024

The facility will install Exit Access signs visible in the any direction from stairwell 9000 on the second and third floors on or before May 31, 2024.
These new Exit Access signs will become part of the monthly exit sign inspection for visibility, illumination and completeness. Once installed, Maintenance supervisor/ designee will monitor for 3 months or until substantial compliance is achieved.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: NEW SKILLED NURSING - Component: 03 - Tag: 0324

Based on observation and interview, the facility failed to maintain cooking equipment in six of six kitchens.

Findings include:

Based on observation and interview on April 2, 2024, between 9:39 a.m. and 9:42 a.m., revealed the following deficiencies:
A. (9:39 a.m.) kitchen, had a staff member that was unaware of the location of the hood suppression system manual activation;
B. (9:42 a.m.) kitchen, cooking operations, it was observed and communicated that the fire suppression system, had a two-step procedure to initiate the suppression system and shut off the fuel supply source. The facility could not produce documentation or verify the system was installed that upon activation of the fire extinguishing system, sources of fuel would shut off automatically.

Reference: NFPA 96-10.4.1

Interview with the maintenance director on April 2, 2024, at 9:42 a.m., confirmed the above deficiencies existed at the time of the survey.





 Plan of Correction - To be completed: 05/05/2024

. The facility director will develop a training program on proper operation of the manual discharge of the cooking hood suppression system. Each employee currently assigned to work in all kitchens will be trained in this operation. This training will be added to the new hire orientation for new employees assigned to work in any kitchen.
This training program will be complete on or before May 15, 2024.
Upon completion of this training the facilities director or other designated staff member will randomly question five kitchen staff members a week working in the kitchens on the procedure of manually discharging the hood suppression systems. This monitor will continue until every questioned staff member demonstrates the knowledge and ability to manually operate the suppression system for four consecutive weeks.
B. On or before May 15th 2024 the facility will work with a fire expert and determine if equipment is installed and is working properly to automatically shut off the gas supply to the six nursing stoves when the suppression system in the hood for each stove is activated. If the equipment and automatic valve are not installed or not working properly the facility will install or fix the equipment on or before July 15, 2004.

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 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: NEW SKILLED NURSING - Component: 03 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system requirements, affecting the entire facility.

Findings include:

Document review on April 2, 2024, between 8:40 a.m. and 8:44 a.m., revealed the following essential electric system deficiencies:
A. (8:40 a.m.) Fuel quality test (taken March 8, 2024) exceeded ASTM specifications due to water and/or sediment levels;
B. (8:42 a.m.) The facility generator monthly load test was inconsistently documented. The monthly load test documentation was unavailable for May, August, and September 2023. The documentation that was provided onsite noted an "Engine Check";
C. (8:44 a.m.) The facility documented battery checks. When interviewed, the facility was unable to specify if the checks were for monthly electrolyte-specific gravity or weekly battery voltage.

Interview with the facilities director on April 2, 2024, at 8:44 a.m., confirmed the deficiencies at the time of the survey.




 Plan of Correction - To be completed: 05/31/2024

A. Generator fuel testing is included in the annual maintenance contract for the generator. The 2024 test results showed the generator fuel did not meet ASTM specifications. Passavant has contracted with Cummins Sales and Service to polish the generator fuel. The process will be complete on or before May 31st, 2024.
B. and C. The Maintenance Supervisor has changed the form used by the maintenance staff to complete generator inspections and testing. The new design includes forced choices to insure more consistent documentation. It includes new places to write battery voltage readings. The new form has space for the maintenance person conducting the inspection or test sign and date the form the same as in the past and additional space for the maintenance supervisor to sign and date the form after reviewing the document for completeness and accuracy. The maintenance staff will be trained on the new form and begin using it immediately. The maintenance supervisor/designee will monitor the appropriate use of the new form for 3 months or until substantial compliance is achieved. He will report his findings to QAPi.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: NEW SKILLED NURSING - Component: 03 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cords in one of over twenty rooms.

Findings include:

Observation on April 2, 2024, at 8:26 a.m., revealed the third-floor storage room (#3050) had a refrigerator plugged into a surge protector.

Interview with the maintenance supervisor on April 2, 2024, at 8:26 a.m., confirmed the power cord deficiency and unplugged the surge protector onsite.





 Plan of Correction - To be completed: 05/05/2024

The refrigerator plugged into a surge protector in the storage room was immediately unplugged and taken away. The Household Coordinator/designee will re-educate staff on the appropriate use of power strips. The Household Coordinator /designee will monitor 6 resident rooms plus storage areas per week for the appropriate use of power strips for 3 months or until substantial compliance is achieved,
Initial comments:Name: COMMUNITY CENTER - Component: 04 - Tag: 0000


Facility ID 163602
Component 04
New Skilled Nursing

Based on a Medicare/Medicaid Recertification Survey completed on April 2, 2024, it was determined that Passavant Retirement and Health 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 (111), protected, non-combustible building, that is fully sprinklered.




 Plan of Correction:


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 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: COMMUNITY CENTER - Component: 04 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system requirements, affecting the entire facility.

Findings include:

Document review on April 2, 2024, between 8:40 a.m. and 8:44 a.m., revealed the following essential electric system deficiencies:
A. (8:40 a.m.) Fuel quality test (taken March 8, 2024) exceeded ASTM specifications due to water and/or sediment levels;
B. (8:42 a.m.) The facility generator monthly load test was inconsistently documented. The facility did not have monthly load test documentation for May, August, and September 2023. The documentation that was provided onsite noted an "Engine Check";
C. (8:44 a.m.) The facility documented battery checks. When interviewed, the facility was unable to specify if the checks were for monthly electrolyte specific gravity or weekly battery voltage.

Interview with the facilities director on April 2, 2024, at 8:44 a.m., confirmed the deficiencies at the time of the survey.





 Plan of Correction - To be completed: 05/31/2024


A. Generator fuel testing is included in the annual maintenance contract for the generator. The 2024 test results showed the generator fuel did not meet ASTM specifications. Passavant has contracted with Cummins Sales and Service to polish the generator fuel. The process will be complete on or before May 31st, 2024.
B. and C. The Maintenance Supervisor has changed the form used by the maintenance staff to complete generator inspections and testing. The new design includes forced choices to insure more consistent documentation. It includes new places to write battery voltage readings. The new form has space for the maintenance person conducting the inspection or test sign and date the form the same as in the past and additional space for the maintenance supervisor to sign and date the form after reviewing the document for completeness and accuracy. The maintenance staff will be trained on the new form and begin using it immediately. The maintenance supervisor/designee will monitor the appropriate use of the new form for 3 months or until substantial compliance is achieved. He will report his findings to QAPI.


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