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

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SILVER STREAM NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  44 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.
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 an Emergency Preparedness Survey completed on March 18, 2024, at Silver Stream 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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0000


Facility ID# 192702
Component 01
Center Building

Based on a Medicare/Medicaid Recertification Survey completed on March 18, 2024, it was determined that Silver Stream Nursing And Rehabilitation Center - Center Building, 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 two-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain portable floor plans outlining designated rated partitions, affecting one floor plan.

Findings Include:

Document review on March 18, 2024, at 9:30 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction provide a portable, accurate floor plan on site to be used during the Life Safety Code Survey.
The Life Safety Code Floor Plan shall include the following:
a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan.
e. Required Exits should be clearly noted; and
f. Shafts Walls
In addition to the above, the following information is required on the portable floor plans for facilities utilizing the Fire Safety Evaluation System (FSES):
dimensions (length and width)
Room numbers and numbers of residents in each room
station locations to include # of nurses at each location
arrows for emergency movement routes
room use must be identified (dining, soiled linen, housekeeping, office, etc.)
where FSES deficiency exists on floor plans.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed accurate floor plans were not available at time of survey.





 Plan of Correction - To be completed: 04/06/2024

The facility has updated floor plans as per the Life Safety Code.
NHA will maintain and store the floor plans for the facility.
NHA / Designee will review floor plans quarterly, then semi-annually and then annually x1 year. NHA Will present findings to QAPI committee.
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 observation, 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:

Observation and document review on March 18, 2024, between 8:30 a.m. and 12:00 p.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.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the building exceeds the maximum allowable story height.






 Plan of Correction - To be completed: 04/06/2024

Facility requests that an FSES be conducted by the Pennsylvania Department of Health to update current FSES.
NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting one of three components

Findings include:

Document review on March 18, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing the following kitchen components had been serviced as required:

a. 1- semi-annual kitchen suppression system inspections.
b. 2- semi-annual kitchen hood cleanings.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 04/06/2024

The facility has scheduled the semi-annual suppression and hood cleaning.
Maintenance Director / designee will obtain timely and review vendor reports and recommendations.
Maintenance Director / designee will conduct audits quarterly x4 to monitor for compliance. Maintenance Director / designee will present findings to the QAPI committee.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.

Findings include:

1. Observation on March 18, 2024, at 9:30 a.m., revealed the facility lacked documentation indicating an annual fire alarm inspection had been conducted.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the missing documentation.

2. Observation on March 18, 2024, at 9:30 a.m., revealed the December 20, 2023, Fire
Alarm Inspection Report checked the system as non-compliant; facility representatives could not provide a copy of the deficiency report for review at time of survey.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the fire alarm deficiency.







 Plan of Correction - To be completed: 04/06/2024

The facility has completed annual fire alarm inspection with documentation.

The facility will obtain a fire alarm inspection report detailing the non-compliance and corrective action completed.

Maintenance Director / designee will schedule annual fire alarm inspections, obtain timely documentation, review fire alarm inspection reports and follow up with the recommendations.

Maintenance Director / designee will conduct review to monitor annual fire alarm inspection is in compliance.
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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined that the facility failed to maintain doors protecting corridor openings affecting two of three levels within this facility.

Findings include:

1. Observations made on March 18, 2024, at 11:14 a.m., revealed the door for room 106 of the Centre Building failed to positively latch.
2. Observations made on March 18, 2024, at 12:00 p.m., revealed gaps in the door for the Nourishment Room, on the second floor, of the Centre Building.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the door deficiencies.







 Plan of Correction - To be completed: 04/06/2024

A new latch for room 106's door has been installed. The gap for the Nourishment Room on the 2nd floor has been repaired.
Maintenance Director / designee will complete an initial audit to identify door latches in need of repair / replacement and gaps in doors in need of correction.
Maintenance Director / designee will audit doors and door latches to ensure compliance. Audits will be done quarterly x3. Maintenance Director / designee will present findings to QAPI committee.
NFPA 101 STANDARD HVAC: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.
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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of three levels.

Findings include:

Document review on March 18, 2024, at 9:30 a.m., revealed the December 20, 2023, fire damper inspection report listed 2- dampers as removed. Supporting documentation was not available for review at time of survey.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 04/06/2024

The facility will obtain an updated report from the vendor on the fire dampers that were identified in the initial report from 12/20/2023.
Maintenance Director / designee will review 12 months of fire damper inspection reports and recommendations.
Maintenance Director / designee will audit damper inspection reports for findings and recommendations. Maintenance Director / designee will audit quarterly x3 and submit findings to the QAPI committee.
NFPA 101 STANDARD Smoking Regulations: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.
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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain designated smoking areas, affecting one of one designated smoking area.

Findings include:

Observation on March 18, 2024, at 11:25 a.m., revealed, the designated smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area and not in the provided ash receptacles. This area contained dried leaf piles.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the discarded cigarette butts.






 Plan of Correction - To be completed: 04/06/2024

Cigarette butts identified were immediately removed by Housekeeping after being identified during annual inspection.
Recreation Director / designee will surveil daily to ensure cigarettes are disposed of properly in ashtray cans.
Recreation Director / designee will conduct audits daily of resident smoking area x4 weeks then weekly x3 months. Recreation Director / designee will present findings to the QAPI committee.
NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to properly conduct the required annual fire door inspection, for one required inspection.

Findings include:

Document review on March 18, 2024, at 9:30 a.m., revealed the facility lacked documentation showing that a complete annual fire door inspection was performed as required. The report listed only the exit doors.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the partial documentation.




 Plan of Correction - To be completed: 04/06/2024

The facility has created a new audit tool for fire door inspections. An audit of all fire doors has been completed.
Maintenance Director / designee will complete an initial audit of the fire doors utilizing the new audit tool.
Maintenance Director / designee will audit monthly x3 months then quarterly x4 months to monitor compliance of annual fire door inspections.
Maintenance Director / designee will present findings to the QAPI committee.
NFPA 101 STANDARD Electrical Systems - 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 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: BUILDING 01 (CENTER BUILDING) - Component: 01 - Tag: 0911

Based on observation and interview on March 18, 2024, between 11:05 a.m. and 11:43 a.m., it was determined facility failed to maintain protection of electrical wiring, affecting one of three levels.

Findings include:

1. Observation at 11:07 a.m., revealed an inoperable light fixture with exposed wiring, inside of the Villa oxygen room.
2 Observation at 11:30 a.m., revealed the basement laundry door was contacting a ceiling mounted junction box, loosening the cover, and exposing the inner wiring.
3. Observation at 11:40 a.m., revealed multiple openings at electrical panels due to missing circuit breaker protection covers, of the Centre building basement.


Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the exposed wiring.







 Plan of Correction - To be completed: 04/06/2024

The identified light fixture in the Villa oxygen room was replaced. The identified ceiling mounted junction box was appropriately affixed above the basement laundry door.
The identified electrical panels in the Center building basement had circuit breaker protection covers replaced.
Maintenance Director / designee will complete an initial audit of the facility light fixtures.
Maintenance Director / designee will surveil mounted junction for proper affixing.
Maintenance Director / designee will complete an initial audit of the facility electrical panels to identify circuit breaker protection covers properly in place.
Maintenance Director / designee will conduct audits of the light fixtures, mounted junction boxes and electrical panels. Audits will be done quarterly x3. Maintenance Director / designee will present findings to the QAPI committee.
NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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 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: BUILDING 01 (CENTER BUILDING) - 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.

Findings include:

Document review on March 18, 2024, at 9:00 a.m., revealed the facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the previous 12 months.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 04/06/2024

The facility has created an audit tool for receptacle testing.
Maintenance Director / designee will conduct an initial audit of the receptacle testing at patient bed locations.
Maintenance Director / designee will audit testing of receptacles. Audit will be conducted quarterly x4.
Maintenance Director / designee will present findings to the QAPI committee.

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 March 18, 2023, at 9:30 a.m., revealed the facility lacked documentation showing the following required emergency generator maintenance items had been conducted:

a. annual load bank.
b. 3-year 4-hour exercise.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 04/06/2024

The facility has completed monthly load bank tests for a 12-month period. The facility has completed and obtained documentation for the 36-month 4-hour exercise.
Maintenance Director / designee will conduct load bank tests on a monthly basis to monitor compliance with K918.
Maintenance Director / designee will review and maintain 36-month 4-hour exercise report.
Maintenance Director / designee will conduct audits of all required load bank tests.
Audits will be conducted monthly x12 months. Maintenance Director / designee will present findings to the QAPI committee.
Initial comments:Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0000


Facility ID# 192702
Component 03
Villa Building

Based on a Medicare/Medicaid Recertification Survey completed on March 18, 2024, it was determined that Silver Stream Nursing And Rehabilitation Center - Villa 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 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 Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common wall separations, affecting two of three components within the facility.

Findings include:

Observation on March 18, 2024, at 11:00 a.m., revealed, the common wall fire doors to Center Building failed to close and latch when tested.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the common wall door deficiency.






 Plan of Correction - To be completed: 04/06/2024

The identified door and latch on the common wall fire doors to the Center Building was repaired for closing and latching.
Maintenance Director / designee will complete an initial audit of common wall fire doors to identify repair / replacement of latches and monitor proper closing and latching.
Maintenance Director / designee will conduct audits of doors and latches to monitor closing and latching. Audits will be conducted quarterly x3.
Maintenance Director / designee will present findings to the QAPI committee.
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 03 (VILLA BUILDING) - Component: 03 - Tag: 0161

Based on observation, 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:

Observation and document review on March 18, 2024, between 8:30 a.m. and 12:00 p.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.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the building exceeds the maximum allowable story height.




 Plan of Correction - To be completed: 04/06/2024

Facility requests that an FSES be conducted by the Pennsylvania Department of Health to update current FSES
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 observation, 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:

Observation and document review on March 18, 2024, between 8:30 a.m.. and 12:00 p.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 March 18, 2024, at 1:15 p.m., confirmed the condition of the communicating stairway.




 Plan of Correction - To be completed: 04/06/2024

Facility requests that an FSES be conducted by the Pennsylvania Department of Health to update current FSES
NFPA 101 STANDARD Number of Exits - Story and Compartment: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.
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 observation, document review, and interview, it was determined the facility lacked two exits, remote from each other, for each floor or fire section of the building, affecting four of four levels within this component.

Findings include:

Observation and document review on March 18, 2024, between 8:30 a.m. and 12:00 p.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 March 18, 2024, at 1:15 p.m., confirmed the lack of exiting.




 Plan of Correction - To be completed: 04/06/2024

Facility requests that an FSES be conducted by the Pennsylvania Department of Health to update current FSES
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain that sprinkler heads were free of lint buildup in one of three levels within this facility.

Observation made on March 18, 2024 at 10:25 a.m., revealed lint build up on the sprinkler head inside of the Wicker Room mechanical closet.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the debris on the sprinkler head.



 Plan of Correction - To be completed: 04/06/2024

The facility immediately cleaned the lint build up on the sprinkler head inside of the Wicker Room's mechanical closet immediately after being identified during annual inspection.
Maintenance Director / designee will complete an initial audit of the sprinkler heads in the facility to monitor that sprinkler heads are free of debris.
Maintenance Director / designee will audit sprinkler heads monthly x3 then quarterly x3.
Maintenance Director / designee will present findings to the QAPI committee.
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: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of three levels.

Findings include:

Observation on March 18, 2024, at 10:55 a.m., revealed, a portable AC unit plugged into an extension cord, on the first floor Wicker Room.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the unauthorized electrical devices.






 Plan of Correction - To be completed: 04/06/2024

The facility immediately removed the extension cord that had a portable AC unit in the Wicker room after being identified during annual inspection.
Maintenance Director / designee will complete an initial audit to identify presence of extension cords in the facility.
Maintenance Director and or designee will audit facility to ensure no extension cords are in use.
Audits will be conducted monthly x3 months then quarterly x 3 quarters.
Maintenance Director will present findings to the QAPI committee.

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: BUILDING 03 (VILLA BUILDING) - Component: 03 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of three levels.

Findings include:

Observation on March 18, 2024, at 11:05 a.m., revealed 20- unsecured oxygen cylinders, basement Oxygen storage room.
.
Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the unsecured oxygen cylinders.





 Plan of Correction - To be completed: 04/06/2024

The facility immediately placed the identified unsecured oxygen cylinders in the basement oxygen storage room, into appropriate oxygen cylinder racks.
Maintenance Director / designee will conduct an initial audit to monitor that oxygen cylinders are properly secured.
Maintenance Director and or designee will audit oxygen cylinders to ensure properly secure weekly x 4 weeks then monthly x 3 months. Maintenance Director will present findings to the QAPI committee.
Initial comments:Name: BUILDING 02 (BACK HALL BUILDING) - Component: 04 - Tag: 0000


Facility ID# 192702
Component 04
Back Hall

Based on a Medicare/Medicaid Recertification Survey completed on March 18, 2024, it was determined that Silver Stream Nursing And Rehabilitation Center - Back Hall, 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 two-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: BUILDING 02 (BACK HALL BUILDING) - Component: 04 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common wall separations, affecting two of three components within the facility.

Findings include:

Observation on March 18, 2024, at 12:05 p.m., revealed, the common wall fire doors separating Center/Back Hall components, failed to latch when tested.

Exit Interview with the Administrator and Maintenance Director on March 18, 2024, at 1:15 p.m., confirmed the common wall deficiency.




 Plan of Correction - To be completed: 04/06/2024

The identified door and latch on the common wall fire doors to the Center/Back hall was replaced for proper closing and latching.
Maintenance Director / designee will complete an initial audit of common wall fire doors to identify repair / replacement of latches and ensure proper closing and latching.
Maintenance Director / designee will conduct audits of doors and latches to ensure closing and latching. Audits will be conducted quarterly x 3 quarters. Maintenance Director will present findings to the QAPI committee.

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