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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SAUNDERS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  40 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.
SAUNDERS 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 July 31, 2024, at Saunders 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 #190402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 31, 2024, it was determined that Saunders Nursing And Rehabilitation 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 four-story, Type III (211), protected ordinary building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of four floors.

Findings include:

Observation on July 31, 2024, at 10:30 a.m., revealed on the first floor, above the common wall fire doors separating skilled/storage buildings, an unsealed penetration around a black wire.

Exit Interview with the Administrator and Maintenance Director on July 31, 2024, at 12:45 p.m., confirmed the penetration.






 Plan of Correction - To be completed: 08/20/2024

The unsealed penetration around the black wire above the fire doors through the common wall at the SNF/Storage buildings was sealed with UL approved 3M WL-2002. The Maintenance Director/designee will inspect work which involves wire runs through a fire wall to assure that penetrations are properly sealed at the time the work is completed.
Maintenance will be in-serviced on importance of not having unsealed penetrations in smoke and fire walls.
Inspection results will be reported at the Quality Improvement Committee Meeting.

NFPA 101 STANDARD Building Construction Type and Height: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.
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 and interview, it was determined the facility failed to maintain the fire resistance rating of the building construction, affecting one of four levels.

Findings Include:

Observation on July 31, 2024, at 10:30 a.m., revealed on the third floor, the west corridor by tub/shower room, an unknown expanding foam product used to fill conduit.

Exit Interview with the Administrator and Maintenance Director on July 31, 2024, at 12:45 p.m., confirmed the prohibited foam substance.





 Plan of Correction - To be completed: 08/20/2024

The unknown expanding foam used to fill a conduit on the 3rd Floor, West Wing near the Tub/Shower Room was removed and replaced with UL approved 3M WL-2002 through the wall penetration system.
The Maintenance Director/designee will ensure that UL approved 3M WL-2002 through the wall penetration system is used to fill conduit or other openings in fire walls.
Quarterly inspections of corridor walls will be conducted to ensure that only approved fire/smoke stop sealants are used to fill openings in the walls.
Maintenance will be in-serviced on importance of not having unsealed penetrations in smoke and fire walls.
Inspection results will be reported at the Quality Improvement Committee Meeting.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to maintain Alcohol Based Hand Rub Dispenser (ABHR), affecting one of four levels.

Findings include:

Observation on July 31, 2024, at 12:00 p.m., revealed on the first floor, in Dining, an ABHR was installed directly above a duplex electrical outlet.

Exit Interview with the Administrator and Maintenance Director on July 31, 2024, at 12:45 p.m., confirmed the ABHR location.





 Plan of Correction - To be completed: 08/20/2024

The Alcohol Based Hand Rub (ABHR) dispenser was relocated away from the electrical outlet in the 1st Floor Dining Room.
The Maintenance Director/designee will ensure that ABHR dispensers are installed in a location away from electrical outlets.
A monthly tour of the building will be completed by the Maintenance Director/designee to make certain that ABHR dispensers are installed correctly. The building tour findings will be reported to the Quality Improvement Committee.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, Section 210.8(B)5 for electrical wiring and equipment, affecting one of four levels.

Findings include:

Observation on July 31, 2024, at 10:55 a.m., revealed on the fourth floor, in Salon, a- non-GFCI outlet located within 6 feet of a sink.

Exit Interview with the Administrator and Maintenance Director on July 31, 2024, at 12:45 p.m., confirmed the unprotected outlet.





 Plan of Correction - To be completed: 08/20/2024

The outlet within six feet of the sink is wired as a GFCI outlet. A sign has been placed on the outlet which indicates that it is a GFCI outlet.
The Maintenance Director/designee will ensure that this outlet and all GFCI outlets are labeled as GFCI outlets.
Maintenance will be in serviced on importance of GFCI outlet labels and placement.

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 designated smoking areas, affecting one of four floors.

Findings include:

Observation on July 31, 2024, at 10:15 a.m., revealed the designated smoking area had numerous cigarette butts strewn on the ground adjacent to and within the designated smoking area and not in the provided ash receptacles.

Exit Interview with the Administrator and Maintenance Director on July 31, 2024, at 12:45 p.m., confirmed the discarded cigarette butts.





 Plan of Correction - To be completed: 08/20/2024

The cigarette butts were removed from the Smoking Area.
Residents and staff were educated about the need to dispose of their cigarette butts in the containers provided.
The Maintenance Director/designee will check the Smoking Area twice daily to ensure that the Smoking Area is free of cigarette butts and debris.
Results of the Smoking Area inspections will be reported to the Quality Improvement Committee.

NFPA 101 STANDARD Electrical Systems - 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.
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 document review and interview, it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations within this facility, affecting the entire facility.

Findings include:

Document review on July 31, 2024, at 9:30 a.m., revealed the facility was unable to provide proper documentation indicating required annual receptacle testing at patient bed locations was performed during the previous 12 months.

Exit Interview with the Administrator and Maintenance Director on July 31, 2024, at 12:45 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 08/20/2024

Documentation of the annual receptacle testing at resident bed locations will include the month, day and year versus month and year. Maintenance team members will be educated about the requirement of documenting the full date of annual receptacle testing. The Maintenance Director will inspect documentation of receptacle testing and will present findings to the Quality Improvement Committee.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance


Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement
Visit the PA Power Port