Nursing Investigation Results -

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

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CENTENNIAL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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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 February 24, 2020, 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 February 24, 2020, it was determined Centennial Healthcare And Rehabilitation 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 483.90(a).

This is a four-story, Type II (222), fire resistive construction, with a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure the means of egress was maintained free of obstructions, affecting one of four floors.

Findings include:

1. Observation on February 24, 2020, at 2:10 p.m., revealed the 2nd floor E-wing corridor was blocked on both sides by wheelchairs, carts and two unattended patient lift devices.

Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the obstructed corridor.





 Plan of Correction - To be completed: 04/14/2020

The equipment blocking the 2nd floor East Wing corridor was removed.

To ensure the means of egress is maintained, the Maintenance Director or Designee will conduct random weekly audits ensuring that equipment is not placed on both sides of the corridors.

The audits will be documented, and the results reported to QAPI for 3 months.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance rating of hazardous areas, in sprinklered locations, affecting two of four floors.

Findings Include:

1. Observation on February 24, 2020, at 12:25 p.m., revealed the following hazardous area door deficiencies:

a. 12:25 p.m., 1st floor, the central supply room door failed to self-close and latch when tested;
b. 12:45 p.m., basement dietary Storage door had non-rated hardware and two unsealed penetrations around the doorknob.;
c. 2:20 p.m., 1st floor lobby storage room was filled with numerous combustible items. There were several holes in the door and frame. There was also a gap along the entire hinge side.

Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the hazardous area door deficiencies.





 Plan of Correction - To be completed: 04/14/2020

The 1st floor central supply room door was repaired to self-close and positively latch.

The basement dietary storage door will have new fire rated hardware installed. The fasteners of the new hardware will appropriately fill the penetrations.

The 1st floor lobby storage room door, frame and hardware will be replaced with fire rated components and will positively latch in frame. The replacement will close to

To ensure the facility maintains doors protecting hazardous areas, the Maintenance Director or Designee will complete random weekly audits of doors to ensure they self-close, positively latch, have no penetrations and are fitted with rated hardware.

The audits will be documented, and the results reported to QAPI for 3 months.

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 protection rating for trash chutes, affecting one of four floors.

Findings include:

1. Observation on February 24, 2020, at 2:00 p.m., revealed the 3rd floor trash chute door failed to self-close and positively latch when tested.

Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the chute door failed to close and latch when tested.






 Plan of Correction - To be completed: 04/14/2020

The 3rd floor trash chute door was repaired to self-close and positively latch.

To ensure the fire protection rating of the trash chutes, the Maintenance Director or Designee will conduct random weekly audits of the chute doors to ensure they self-close and positively latch.

The audits will be documented, and the results reported to QAPI for 3 months.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, per NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1., affecting one of four floors.

Findings include:

1. Observation on February 24, 2020, at 1:00 p.m., revealed above the suspended ceiling by 4th floor center stair tower, there was an electrical box with an open duplex cover, exposing the inner wiring.


Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the exposed wiring.





 Plan of Correction - To be completed: 04/14/2020

The duplex cover was replaced on the electrical box above the suspended ceiling by the 4th floor center stair tower.

To ensure the facility maintains protection of electrical wiring, the Maintenance Director or Designee will conduct random monthly audits of electrical outlets ensuring no exposed wiring.

Audit results will be reported to QAPI for 3 months.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of surge protectors, affecting one of three floors.

Findings include:

1. Observation on February 24, 2020, at 2:15 p.m., revealed in basement housekeeping office, there was a microwave plugged into a surge protector.

Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the microwave was plugged into a surge protector.






 Plan of Correction - To be completed: 04/14/2020

The microwave was unplugged from the surge protector and plugged directly into a receptable.

To prohibit the unauthorized use of surge protectors, the Maintenance Director or Designee will conduct monthly audits in potential areas of non-compliance.

The audits will be documented, and the results reported to QAPI for 3 months.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage, affecting one of four floors.

Findings include:

1. Observation on February 24, 2020, at 12:30 p.m., revealed there was a freestanding E-size oxygen cylinder inside the 1st floor oxygen storage room.

Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the cylinder was not secured.





 Plan of Correction - To be completed: 04/14/2020

The oxygen cylinder was secured in a carrier.

To ensure the facility maintains oxygen cylinder storage by properly securing oxygen cylinders in carriages, the Maintenance Director or Designee will conduct monthly audits of oxygen storage.

The audits will be documented, and the results reported to QAPI for 3 months.


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