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

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MEADOWVIEW REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  47 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.
MEADOWVIEW REHABILITATION AND NURSING 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 June 13, 2024, at Meadowview Rehabilitation and Nursing 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# 183202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 13, 2024, it was determined Meadowview Rehabilitation and Nursing Center 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 III (200), unprotected ordinary building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation, document review, and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.

Findings include:

Observation and document review on June 13, 2024, at 10:15 a.m., revealed the facility had been classified as a two-story, Type III (200), unprotected ordinary construction, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by one story.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the building exceeds the maximum allowable story height.




 Plan of Correction - To be completed: 07/31/2024

This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.


Facility request that the Pa Department of Health Life safety Division uses Facility FSES plan on file. The facility is requesting a TLW as with an FSES.

NFPA 101 STANDARD Means of Egress - General: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.
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 observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of seven exit discharges.

Findings include:

Observation on June 13, 2024, at 10:50 a.m., revealed, in basement enclosed Smoking Courtyard, the gates leading to the public way were locked, impeding full and instant use in case of emergency.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the obstructed egress path.




 Plan of Correction - To be completed: 08/12/2024

0211 facility failed to maintain the means of egress free of impediment, affecting one of seven exit discharges.
1 .Gates leading to the public courtyards will have full open way for emergency by installing mag locks that will release when fire alarm is activated.

a.The facility will submit to plans to plan review for approval.
b. Once the facility receives plan review approval, the facility will submit t DNCF for approval.

2. Inservice maintenance department by Administrator on emergency assess to courtyard after fire alarm reset- will check gates closed.

3. Audit will be conducted weekly to assure proper function of gates weekly x 4 weeks then monthly x2.

4. Audits will be reviewed by maintenance director or designee at Quality Assurance to determine further action required.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
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 observation, document review, and interview, it was determined the facility failed to maintain the requirements for smoke compartments, affecting one of seven smoke zones within this facility.

Findings include:

Observation and document review on June 13, 2024, at 10:00 a.m., revealed the Ground Floor, E-wing, front corridor smoke compartment exceeded the maximum allowance of 22,500 square feet.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the smoke compartment exceeded the maximum allowable square footage.




 Plan of Correction - To be completed: 07/26/2024

0371 Facility failure to maintain the requirements for smoke compartments, affecting one of seven smoke zones within this facility.

1. Facility request that the PA Department of Health Life safety Division uses Facility FSES plan on
File.

NFPA 101 STANDARD HVAC: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.
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 observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of two levels.

Findings include:

Document review on June 13, 2024, at 12:00 p.m., revealed a portable AC unit was vented directly above the suspended ceiling, on the first floor, in Kitchen Manager Office.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the prohibited venting.




 Plan of Correction - To be completed: 07/31/2024

0521 Facility failed to maintain Heating, ventilation and Air Conditioning (HVAC) equipment, affecting one of two levels
1.AC unit removed from Dietary Manager office
2. in service maintenance staff by Administrator regarding proper ventilation for heating and air conditioning equipment
3,.Audit will be conducted by maintenance director or designee of Manager offices to assure proper ventilation heat and air conditioners. Weekly x 4 weeks then monthly x 2 months
4. Audits will be reviewed by maintenance director or designee at Quality Assurance to determine further action required.

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas in two instances outside the facility, affecting one of two levels.

Findings include:

Observation on June 13, 2024, at 10:30 a.m., revealed 2- facility staff smoking directly outside the building, E-wing Ambulance Entrance. This is not the designated smoking area.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the employees smoking.




 Plan of Correction - To be completed: 07/31/2024

0741 Facility to maintain smoking areas in two instances outside the facility, affection one of two levels.
1. Staff were removed from non-smoking area
2. In service conducted by staff educator to all staff educating smoking not permitted on Facility property
3. Maintenance Director or designee will audit entrances of building to assure no staff smoking those areas. Audits will be conducted weekly x 4 weeks then monthly x 2 months
4. Audits will be reviewed by Maintenance Director or designee at Quality Assurance to determine further action required

NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels.

Findings include:

Observations on June 13, 2024, revealed the following electrical wiring deficiencies:

a. 10:40 a.m., basement E-wing, above smoke doors by Nurse Station, exposed wires.
b. 10:55 a.m., basement D-wing, above smoke doors by room 1, exposed wires.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.




 Plan of Correction - To be completed: 07/31/2024

0911 Facility failed to maintain protection of electrical wiring effecting one of two level
a. Basement E wing above smoke doors by nurses station exposed wires - wires were placed in Junction boxes
b. Basement D wing above smoke doors by room 1 exposed wires- wires were placed in junction boxes.
2. In service conducted by Maintenance Director to maintenance staff to assure no wires are exposed
3. Audits will be conducted by Maintenance Director or designee of all smoke doors to assure not wires exposed weekly x 4 weekly then monthly x 2 months
4. Audits will be reviewed by Maintenance Director or designee at Quality Assurance to determine further action required

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of two levels.

Findings include:

Observations on June 13, 2024, revealed the following electrical deficiencies:

a. 11:00 a.m.. power strip plugged into a power strip, basement Memory Care Office.
b. 11:50 a.m., extension cord in use fished above the suspended ceiling and powering a TV, basement conference room.

Exit Interview with the Administrator and Maintenance Director on June 13, 2024, at 12:40 p.m., confirmed the unauthorized electrical devices.





 Plan of Correction - To be completed: 07/31/2024

0920 Facility failed to prohibit the unauthorized use of electrical devices affection one of two levels
a. Power strip removed from memory care office
b. Extension cord removed from ceiling in the conference room.
2. IN service conducted by maintenance Director or designee to staff to assure no extension cords are used or power strip are used in incorrect manor
3. Audits will be conducted by maintenance director or designee to assure no extension cords or power strips not being used.
4. Audits will be reviewed by Maintenance Director or designee at Quality Assurance to determine further action required.


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