Nursing Investigation Results -

Pennsylvania Department of Health
CARING HEART REHABILITATION AND NURSING CENTER
Building Inspection Results

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CARING HEART REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  33 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.
CARING HEART 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 December 23, 2019, at Caring Heart 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 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0000


Facility ID# 191802
Component 01
Main (Cliveden) Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 23, 2019, it was determined Caring Heart Rehabilitation and Nursing Center - Main (Cliveden) Building 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 five-story, Type II (222), fire resistive construction, with a penthouse, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas with smoke separation from other spaces, in sprinklered locations, affecting one of six levels.

Findings include:

1. Observation on December 23, 2019, at 11:20 a.m., revealed the boiler room double doors inactive leaf did not positively latch into its frame when closed, ground floor, Cliveden.

Interview at the exit conference with the Facility Administrator and Director of Maintenance on December 23, 2019, at 3:00 p.m., confirmed the non-latching door.




 Plan of Correction - To be completed: 02/13/2020

Boiler room inactive leaf has been adjusted and now positively latches. Maintenance Director will follow up and create an audit and monthly audits will continue thereafter with results reported to the QA Committee by the maintenance director or designee for the next 3 months.
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 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper use of electrical devices, affecting two of six levels within this component.

Findings include:

1. Observation on December 23, 2019, between 11:50 a.m. and 12:32 p.m., revealed the improper use of surge protectors, in the following locations:

a. 11:50 a.m., 5th floor, Cliveden, B-side, lounge and recreation, a heater was plugged into a surge protector;

b. 12:32 p.m., 4th floor, Cliveden, A-side, chart room, a microwave was plugged into a surge protector.

Interview at the exit conference with the Facility Administrator and Director of Maintenance on December 23, 2019, at 3:00 p.m., confirmed the unauthorized use of electrical devices.

*************************************

An onsite Revisit conducted on February 11, 2020, between 8:00 a.m. and 10:30 a.m., revealed the following:

Item #1a - Not Completed. 5th floor, Cliveden, B-side, lounge and recreation, a heater was plugged into a surge protector.

Interview at the exit conference with the Facility Administrator and Director of Maintenance on February 11, 2020, at 1:00 p.m., confirmed the unauthorized use of electrical devices.

All other deficiencies listed under this tag were corrected.




 Plan of Correction - To be completed: 02/14/2020

Plan of Correction:
A) The surge protector has been removed from the area and 5th floor Cliveden lounge fireplace is plugged directly into the wall.

B) The surge protector has been removed from the area and the 4th floor Cliveden's microwave in chart room is plugged directly into the wall.

All staff have been in serviced on the importance of properly using surge protectors. Maintenance Director will follow up and create an audit and weekly audits will continue thereafter with results reported to the QA Committee by the maintenance director or designee for the next 3 months.
Initial comments:Name: BUILDING A CONVERSION - Component: 02 - Tag: 0000


Facility ID# 191802
Component 02
Mt. Airy Building A

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 23, 2019, it was determined Caring Heart Rehabilitation and Nursing Center - Mt. Airy Building A was not in compliance with the 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 five-story, Type II (222), fire resistive construction, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: BUILDING A CONVERSION - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain protection from hazardous materials, affecting one of five levels.

Findings Include:

1. Observation on December 23, 2019, at 12:35 p.m., revealed large boxes of furniture were stored in the corridor means of egress and inside rooms of the entire wing, 4th floor, Mt. Airy.

Interview at the exit conference with the Facility Administrator and Director of Maintenance on December 23, 2019, at 3:00 p.m., confirmed separation of combustible storage was not provided.
*************************************

An onsite Revisit conducted on February 11, 2020, between 8:00 a.m. and 10:30 a.m., revealed the following:

Item #1 - Not Completed. Large boxes of furniture were stored in the corridor means of egress and inside rooms of the entire wing, 4th floor, Mt. Airy. The large boxes of furniture were removed from the corridor means of egress. There were boxes stored inside rooms without smoke resistant separation from the corridors. The rooms lacked self-closing hardware.

Interview at the exit conference with the Facility Administrator and Director of Maintenance on February 11, 2020, at 1:00 p.m., confirmed separation of combustible storage was not provided.





 Plan of Correction - To be completed: 02/14/2020

All the doors of rooms containing storage have had self closing hardware installed.
These are all temporary storage and are in the process of being cleared out. Maintenance Director will follow up and create an audit and monthly audits will continue thereafter with results reported to the QA Committee by the maintenance director or designee for the next 3 months.

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