Nursing Investigation Results -

Pennsylvania Department of Health
SAYRE HEALTH CARE 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
SAYRE HEALTH CARE CENTER
Inspection Results For:

There are  11 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.
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 September 18, 2019, it was determined that Sayre Health Care Center was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73 REQUIREMENT Establishment of the Emergency Program (EP):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.
The [facility, except for Transplant Center] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:

*[For hospitals at 482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

*[For CAHs at 485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach.
Observations:
Name: - Component: -- - Tag: 0001

Based on an Emergency Preparedness Survey completed on September 18, 2019, it was determined that Sayre Health Care Center was not in compliance with the requirements of 42 CFR 483.73.

Findings include:

1. Review of documentation on September 18, 2019, at 9:15 a.m., revealed the facility lacked an Emergency Preparedness program using an all-hazards approach risk assessment to develop the program.
1. Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
2. Include strategies for addressing emergency events identified by the risk assessment.
3. Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
4. Include a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the LTC facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 10/15/2019

The facility shall develop and maintain a comprehensive emergency preparedness program, utilizing an all hazards approach.
The facility shall have an Emergency Preparedness Plan that uses an all-hazards approach, which includes the following: missing residents, strategies that address emergency events identified by the risk assessment. It will address the resident population for residents at risk, and the type of services the facility can provide in an emergency, with the continuity of operations, including delegation of authority and succession plans.
The plan shall include a process for collaboration with local tribal, regional, State, or Federal emergency preparedness officials, to maintain an integrated response during a disaster or emergency situation.
The facility shall maintain documentation of efforts to contact such officials when applicable to verify participation in collaborative and cooperative planning efforts.
The facility IDT shall meet to review and update their Risk assessment and formulate their plan to provide an all hazard approach.

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


Facility ID# 192102
Component 10
Replacement Facility

Based on a Medicare/Medicaid Recertification Survey completed on September 18, 2019, 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, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: A0202 - Component: 10 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls, affecting one of eight smoke compartments within the facility.

Findings include:

1. Observation on September 18, 2019, at 10:15 a.m., revealed the corridor wall had a penetration around the door stop located at resident room #303.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the penetration.




 Plan of Correction - To be completed: 10/15/2019

The penetration around the door stop near room # 303 has been corrected by Maintenance and the penetration sealed.
The Maintenance Director shall be educated by the NHA /designee on the need to verify corridor walls have no open penetrations.
Monthly random audit shall be completed by maintenance staff/designee to verify compliance with the regulation. Immediate correction of open penetrations shall be completed as they are identified.
Audits shall continue for three months and be sent to the monthly QA for a review.


NFPA 101 STANDARD Corridor - Doors: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.
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 corridor doors, affecting two of eight smoke compartments within the facility.

Findings include:

1. Observation on September 18, 2019, between 10:05 a.m and 10:55 a.m., revealed:

a. 10:05 a.m. - Resident room #609 had an isolation door hanging bag, preventing the door from closing and latching.

b. 10:55 a.m. - Resident room #401 needed excessive force to close and latch.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the corridor door obstructions.




 Plan of Correction - To be completed: 10/15/2019

The isolation door bag on room 609 shall be removed by nursing to allow for a positive closure and latching of the door.
The door to room 401 shall be corrected by maintenance to allow for closure and a positive latch without excessive force to close the door.
The maintenance staff shall be educated by the NHA/designee on the need to verify that room doors have a positive closure and latch.
A monthly random audit shall be completed by maintenance staff to verify doors have a positive closure and latch. Doors identified with an issue shall be corrected as they are identified.
The monthly random audits for door closure shall be sent to the monthly QA meeting for a review of issues. This shall continue for three 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 September 18, 2019, at 9:20 a.m., revealed the facility lacked records to support the required four-year testing and inspection of HVAC fire/smoke dampers.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 10/15/2019

The Davis-Ulmer company shall be contacted by the NHA/designee for the four-year testing and inspection of the HVC fire/smoke dampers, they are working on a date for scheduling the inspection.
The Maintenance Director shall be educated by the NHA/designee on the need to verify compliance with the required regulation.
The Maintenance Director/designee will maintain a record for the completion of the inspection to verify compliance with the four-year testing of the HVC fire/smoke dampers.
A copy of the testing shall be sent to the QA meeting to verify compliance.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: A0202 - Component: 10 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain records, affecting eight of eight smoke compartments within the facility.

Findings include:

1. Review of documentation on September 18, 2019, at 9:25 a.m., revealed the facility lacked records of the required annual fire door inspection.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 10/15/2019

Davis-Ulmer Company shall be contacted by the NHA/designee to schedule the annual fire door inspection.
The Maintenance Director shall be educated by the NHA/designee to verify that the annual fire door inspection is completed.
The Maintenance Director shall maintain a record of annual fire door inspections.
A copy of the testing log shall be sent to the QA for a review and verification that the inspection was completed as per regulation.

NFPA 101 STANDARD Electrical Systems - Other: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 - 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: A0202 - Component: 10 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain emergency generators in one instance, affecting the entire facility.

Findings include:

1. Observation on September 18, 2019, at 9:43 a.m., revealed the facility lacked an externally located emergency stop.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the lack of an externally located emergency stop.




 Plan of Correction - To be completed: 10/15/2019

The emergency generator shall have an emergency stop located externally on the generator.
The Maintenance Director shall be educated by the NHA/designee to verify the generators have the external stop button.
A copy of the work order showing the completion of the emergency stop button has been added to the generator shall be sent to the QA for a review and verification that the emergency stop has been completed as per regulation

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: A0202 - Component: 10 - Tag: 0914

Based on document review and interview, the facility failed to maintain electrical receptacles, affecting the entire facility.

Findings include:

1. Review of documentation on September 18, 2019, at 9:28 a.m., revealed the facility lacked documentation for a required annual electrical receptacle inspection.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 10/15/2019

The required annual electrical receptacle inspection shall be scheduled by the maintenance director.
The Maintenance Director shall be educated by the NHA/designee on the importance of verifying the annual electrical receptacle inspection is completed as per regulation.
The documentation shall be sent to the QA when it is completed to verify compliance with the regulation.

NFPA 101 STANDARD Electrical Equipment - 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 Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)
Observations:
Name: A0202 - Component: 10 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one instance, affecting one of eight smoke compartments within the facility.

Findings include:

1. Observation on September 18, 2019, at 9:50 a.m., revealed the bed located in resident room #501 (b side) was placed against an electrical receptacle.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the bed placed against an electrical receptacle.




 Plan of Correction - To be completed: 10/15/2019

The bed in 501 b side has been removed from the room per resident request they do not utilize the bed and request to sleep in the chair.
The Maintenance Director shall be educated by the NHA/designee to verify that beds are not placed against the electrical outlets in the resident rooms.
A random monthly audit shall be completed by the maintenance staff to verify compliance with the regulation.
The audits shall be sent to the monthly QA meetings for three months for a review of any ongoing issues.

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: A0202 - Component: 10 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one instance, affecting one of eight smoke compartments within the facility.

Findings include:

1. Observation on September 18, 2019, at 11:15 a.m., revealed the activity room had an electrical multiplier in use.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the electrical multiplier in use.




 Plan of Correction - To be completed: 10/15/2019

The electrical multiplier has been removed from the activity room.
The Managers shall be educated by the NHA/designee that electrical multipliers are not to be utilized as per life safety code.
The Maintenance director/designee shall complete a weekly random audit for three months to verify compliance with the regulation.
The audits shall be reviewed during the QAA monthly meeting. This shall be completed for three months or longer if issues are noted.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: A0202 - Component: 10 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain medical gas storage in two instances, affecting one of eight smoke compartments within the facility.

Findings include:

1. Observation on September 18, 2019, between 11:00 a.m. and 11:01 a.m., revealed the following items in the medical gas storage room:

a. 11:00 a.m. - seven unsecured oxygen cylinders.

b. 11:01 a.m. - O2 cylinders stored were not separated Full/Empty.

Exit interview with the facility administrator and facility representative #1 on September 18, 2019, at 12:10 p.m., confirmed the unsecured cylinders and cylinders not being separated.




 Plan of Correction - To be completed: 10/15/2019

The oxygen cylinders in the medical gas storage area have been placed in a secured holder. The oxygen tanks shall also be stored separated by full tanks and empty tanks.
The nursing staff shall be educated by the NHA/designee on the importance of securing all tanks in a holder and according to full and empty tanks per regulations.
The Maintenance director/designee shall complete a random weekly audit to verify compliance with the regulations.
The weekly audits shall be sent to the QAA monthly for a compliance review.


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