Pennsylvania Department of Health
SAYRE HEALTH CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SAYRE HEALTH CARE 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 April 30, 2024, at Sayre Health Care Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: A0202 - Component: 10 - Tag: 0000

Facility ID# 192102
Component 10
Replacement Facility

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2024, it was determined that Sayre Health Care 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 483.70(a).

This is a one story, Type V (111), protected, wood-frame structure, with unused attic spaces, that is fully sprinklered.

Plan of Correction:

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: A0202 - Component: 10 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress in one location, affecting one of one floors.

Findings include:

1. Observation on April 30, 2024, At 10:15 a.m., Unit 1, revealed the Dietary walk-in cooler had a hasp lock installed that would lock the door from egress if in the room.

Interview at the time of the exit conference with the Assistant Administrator and Maintenance Supervisor on April 30, 2024, At 12:15 p.m., confirmed the egress deficiency.

Plan of Correction - To be completed: 05/22/2024

The Maintenance Director has removed the hasp lock that was installed on the refrigerator door.
The original handle and lock were repaired to prevent the need for the hasp lock.

The repairs were completed 4/30/2024.

The Maintenance Director and Director of Dining Services were both educated by the Administrator on the potential hazards to block egress from the kitchen cooler.

The Maintenance Director/ Designee will complete random monthly audits and bring them to the monthly QA meeting for 3 months for review.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: A0202 - Component: 10 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting two of eight smoke compartments.
Findings include:
1. Observation on April 30, 2024, between 10:45 a.m., and 10:55 a.m, revealed the following:
a. At 10:45 a.m., Unit 2, Resident room #602 door, required adjustment to fully latch within the corresponding door frame assembly.
b. At 10:48 a.m., Unit 2, Resident room #604 door, required adjustment to fully latch within the corresponding door frame assembly.
c. At 10:55 a.m., Unit 2, Resident room #709 door, required adjustment to fully latch within the corresponding door frame assembly

Interview at the time of the exit conference with the Assistant Administrator and Maintenance Supervisor on April 30, 2024, At 12:15 p.m., confirmed the doors failed to fully latch when tested.

Plan of Correction - To be completed: 05/22/2024

The Maintenance Director adjusted the doors and latches for rooms 602, 604 and 709 to make sure that they completely latch when closed.

The doors to room 602, 604 and 709 were adjusted to ensure latching on 4/30/2024.

The Maintenance Director was educated by the facility Administrator on checking the doors to be sure that they latch properly and have no gaps in the smoke barrier doors.

The Maintenance Director/Designee will complete random monthly audits to ensure doors are latching properly for the regulated protection for smoke compartments. The audits will be brought to the monthly QA meeting for 3 months for review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: A0202 - Component: 10 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one-half hour fire resistance rating, affecting two of eight smoke compartments.
Findings include:
1. Observation on April 30, 2024, at 10:25 a.m., revealed an unsealed penetration located above the cross-corridor doors in Unit 1, near Resident room #405.

Interview at the time of the exit conference with the Assistant Administrator and Maintenance Supervisor on April 30, 2024, At 12:15 p.m., confirmed the penetration.

Plan of Correction - To be completed: 05/22/2024

The penetration located above the cross-corridor doors on unit 1, near residents' room #405 was repaired by the Maintenance Director on 4/30/24.

The Maintenance Director was educated by the Administrator to be sure to fix any unsealed penetrations immediately.

Monthly random audits will be completed by the Maintenance Director/Designee to verify compliance with life safety regulations. The monthly Audits will be brought to monthly QA meeting to review for 3 months

NFPA 101 STANDARD HVAC:

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.

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: A0202 - Component: 10 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to maintain key components of the heating, ventilation, and cooling (HVAC) system, affecting the entire facility.

Findings include:

1. Review of documentation on April 30, 2024, at 11:45 a.m., revealed the facility lacked records to support the required four-year testing and inspection of HVAC fire/smoke dampers.

Interview at the time of the exit conference with the Assistant Administrator and Maintenance Supervisor on April 30, 2024, at 12:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/22/2024

The HVAC fire/smoke dampers were out of inspection compliance resulting in a possible hazard. Last Inspection was completed in November 2019.

The Maintenance Director was educated on the importance of the inspection of the dampers by the facility Administrator. This has been scheduled to occur on May 20, 2024. And will be maintained every 4 years.

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