Pennsylvania Department of Health
CENTENNIAL HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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CENTENNIAL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  43 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.
CENTENNIAL HEALTHCARE 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 January 29, 2024, at Centennial Healthcare 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: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #193902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2024, it was determined that Centennial Healthcare And Rehabilitation Center 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

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

Findings include:

Document review on January 29, 2024, at 8:00 a.m., revealed the facility could not produce documentation of an annual 90-minute test.

Exit interview with the Administrator and Maintenance Director on January 29, 2024, at 11:00 a.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 03/20/2024

The 90-minute testing of the battery back-up lighting was performed, and documentation is available on site.

To ensure the emergency back-up lighting illuminates, the Facilities Director or Designee will test monthly and oversee annual testing as required and audit monthly for 3 months.

The audits will be reported to QAPI.

The NHA or Designee will monitor for compliance.

NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to maintain and inspect exit signage, affecting the entire facility.

Findings include:

Document review on January 29, 2024, at 8:00 a.m., revealed the facility could not produce documentation of monthly exit sign inspections.

Exit interview with the Administrator and Maintenance Director on January 29, 2024, at 11:00 a.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 03/20/2024

Exit signs in the facility were inspected.

The Facilities Director or Designee will inspect exit signs monthly.

The inspections will be documented and available on site for review. The outcome of the inspections will be reported to QAPI monthly for 3 months.

The NHA or Designee will monitor for compliance.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of five levels in the facility.

Findings include:

Observation on January 29, 2024, at 9:47 a.m., revealed, on the fourth floor east side, a missing ceiling tile in the Storage Room which could delay the activation of the sprinkler.

Exit interview with the Administrator and Maintenance Director on January 29, 2024, at 11:00 a.m., confirmed the missing ceiling tile.



 Plan of Correction - To be completed: 03/20/2024

The missing ceiling tile in the 4th floor storage room was replaced.

The Facilities Director or Designee will conduct audits of the storage areas to ensure ceiling tiles are intact. The audits will be conducted weekly for 4 weeks, then monthly for 3 months.

The results of the audits will be reported to QAPI.

The NHA or Designee will monitor for compliance.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of rubbish chutes, affecting one of five levels in the facility.

Findings include:

Observation on January 29, 2024, at 9:36 a.m., revealed, on the fourth floor, the door hardware on the Trash Chute room was not fire rated.

Exit interview with the Administrator and Maintenance Director on January 29, 2024, at 11:00 a.m., confirmed the lack of fire rated hardware.



 Plan of Correction - To be completed: 03/20/2024

The door hardware on the 4th floor trash chute room was changed to appropriate fire rated hardware.

The Facilities Director will visually inspect the rubbish and linen chutes to ensure only fire-rated hardware is maintained.

The visual inspection will be documented and reported to QAPI monthly for 3 months.

The Director of Facilities Management or designee will monitor for compliance.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

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

Findings include:

Document review on January 29, 2024, at 8:00 a.m., revealed the facility could not provide documentation of an annual 90 minute load bank test.

Exit interview with the Administrator and Maintenance Director on January 29, 2024, at 11:00 a.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 03/20/2024

The 90-minute load bank test was conducted for the emergency generator and documentation is available on site.

Facilities Director or Designee will ensure annual documentation of the testing for the generator is completed.

The NHA or Designee will monitor for compliance.


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