Pennsylvania Department of Health
SILVER STREAM NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 49 surveys for this facility. Please select a date to view the survey results.

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SILVER STREAM NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on a Revisit to an Emergency Preparedness Survey completed on December 16, 2024, it was determined that Silver Stream Nursing and Rehabilitation Center was in substantial compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0000

Facility ID# 192702
Component 01
Center Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 16, 2024, it was determined that Silver Stream Nursing And Rehabilitation Center - Center Building was not in substantial 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, with a basement, 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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating for building construction, affecting the entire component.

Findings include:

1. Document review on December 16, 2024, at 8:15 a.m., revealed the Center Building is a two-story structure, with a basement, classified as 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 December 16, 2024, at 11:45 a.m., confirmed the building exceeds the maximum allowable story height.

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Document review and interview during an onsite revisit conducted on February 5, 2025, between 11:30 a.m. and 1:30 p.m., revealed the following:

Item 1 - Not Completed. The story height exceeds the maximum allowance for this construction type by one story. The facility is working to obtain an FSES.

Exit Interview with the Administrator and Maintenance Director on February 5, 2025, at 1:30 p.m., confirmed the construction type and story height of the building

Plan of Correction - To be completed: 02/11/2025

The facility requested and submitted a TLW on 1/9/2025 and completed and submitted an FSES on 2/11/2025.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

Document review on December 16, 2024, at 8:15 a.m., revealed the following deficiencies:

a. No weekly visual inspections performed after 7/18/2024;
b. No weekly battery voltage inspections performed after 7/18/2024;
c. No monthly battery conductance testing performed after 7/2024;
d. No monthly exercise of the generator for 30 minutes performed after 7/2024;
e. No monthly operation of transfer switches performed after 7/2024;
f. No annual fuel quality test;
g. Generator inspection dated March 21, 2024 noted the generator was wet stacked and there were fuel injector warnings.

Exit Interview with the Administrator and Maintenance Director on December 16, 2024, at 11:45 a.m., confirmed the lack of documentation.

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Document review and interview during an onsite revisit conducted on February 5, 2025, between 11:30 a.m. and 1:30 p.m., revealed the following:

Item e - Not completed. No monthly operation of transfer switches performed after 7/2024

Item f - Not completed. No annual fuel quality test

Item g - Not completed. Generator inspection dated March 21, 2024 noted the generator was wet stacked and there were fuel injector warnings.

Exit Interview with the Administrator and Maintenance Director on February 5, 2025, at 1:30 p.m., confirmed the confirmed the lack of documentation. Facility is waiting for delivery of parts to be able to complete these tasks.

Plan of Correction - To be completed: 03/05/2025

The facility will comply with emergency generator weekly visual checks, weekly battery voltage checks, monthly battery conductance testing, 30-minute monthly exercise, monthly operation of transfer switch and annual fuel tests.
The facility completed a fuel analysis on 1/22/2025 and failed the analysis. The facility requested for fuel to be polished to successfully pass analysis and this work was completed on 2/13/2025. A TLW was requested on 1/24/2025 to fix the injector warning to address the deficiency from the 3/21/2024 inspection.
The facility ran a monthly exercise on 2/13/2025.
The facility corrected the wet stacks on 5/13/2024.
All residents and areas have the potential to be affected.
The Maintenance Director will be educated on the importance of conducting weekly and monthly inspections and scheduling the yearly test.
LNHA will monitor all weekly, monthly and yearly tests.
LNHA will monitor future generator inspection deficiencies for appropriate and timely corrections.
LNHA / designee will audit weekly inspections, weekly x4 then bi-weekly x2 then monthly x2

LNHA / designee will audit monthly inspections x3

LNHA / designee will audit yearly tests, yearly.

LNHA / designee will audit generator inspection deficiencies quarterly.

Initial comments:Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0000

Facility ID# 192702
Component 03
Villa Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 16, 2024, it was determined that Silver Stream Nursing And Rehabilitation Center - Villa Building was not in substantial 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 V (000), unprotected wood frame building, with a basement and unused attic, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Observations:
Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating for building construction, affecting the entire component.

Findings include:

1. Document review on December 16, 2024, at 8:15 a.m., revealed the Villa Building component is a two-story structure, with a basement, classified as Type V (000), unprotected wood frame construction. The story height exceeds the maximum allowance for this construction type by one story.

Exit Interview with the Administrator and Maintenance Director on December 16, 2024, at 11:45 a.m., confirmed the building exceeds the maximum allowable story height.

********************************************************************************
Document review and interview during an onsite revisit conducted on February 5, 2025, between 11:30 a.m. and 1:30 p.m., revealed the following:

Item 1 - Not Completed. The story height exceeds the maximum allowance for this construction type by one story. The facility is working to obtain an FSES.

Exit Interview with the Administrator and Maintenance Director on February 5, 2025, at 1:30 p.m., confirmed the construction type and story height of the building

Plan of Correction - To be completed: 02/11/2025

The facility requested and submitted a TLW on 1/9/2025 and completed and submitted an FSES on 2/11/2025.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0225

Based on document review and interview, it was determined the facility failed to maintain the fire resistance rating of stairway enclosures, affecting three of four levels within this component.

Findings Include:

1. Document review on December 16, 2024, at 8:15 a.m., revealed the communicating stairway enclosure lacked one hour fire rated construction, due to the presence of wired glass in wooden frames, non-rated doors, frames, and hardware utilized within the stairway.

Exit Interview with the Administrator and Maintenance Director on December 16, 2024, at 11:45 a.m., confirmed the condition of the communicating stairway.

**************************************************************************
Document review and interview during an onsite revisit conducted on February 5, 2025, between 11:30 a.m. and 1:30 p.m., revealed the following:

Item 1 - Not Completed. The communicating stairway enclosure lacked one hour fire rated construction, due to the presence of wired glass in wooden frames, non-rated doors, frames, and hardware utilized within the stairway.

Exit Interview with the Administrator and Maintenance Director on February 5, 2025, at 1:30 p.m., confirmed the condition of the communicating stairway. Facility is working to obtain an FSES

Plan of Correction - To be completed: 02/11/2025

The facility submitted a FSES on 2/11/2025.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0241

Based on document review and interview, it was determined the facility lacked two approved exits remote from each other, for each floor or fire section of the building, affecting the entire component.

Findings include:

Document review on December 16, 2024, at 8:15 a.m., revealed the facility lacked acceptable fire exits, with exiting reliant on the communicating stair way within the center of the building.

Exit Interview with the Administrator and Maintenance Director on December 16, 2024, at 11:45 a.m., confirmed the lack of exiting.

********************************************************************
Document review and interview during an onsite revisit conducted on February 5, 2025, between 11:30 a.m. and 1:30 p.m., revealed the following:

Item 1 - Not Completed. The facility lacked acceptable fire exits, with exiting reliant on the communicating stairway within the center of the building.

Exit Interview with the Administrator and Maintenance Director on February 5, 2025, at 1:30 p.m., confirmed the facility lacked acceptable fire exits. Facility is working to obtain an FSES

Plan of Correction - To be completed: 02/11/2025

The facility submitted a FSES on 2/11/2025.

Initial comments:Name: BUILDING 02 (BACK HALL BUILDING) - Component: 04 - Tag: 0000

Facility ID# 192702
Component 04
Back Hall

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 16, 2024, it was determined that Silver Stream Nursing And Rehabilitation Center - Back Hall, was in substantial 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 II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

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