Pennsylvania Department of Health
SENA KEAN 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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SENA KEAN 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 April 30, 2025, at Sena Kean 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: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #195402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2025, it was determined that Sena Kean Nursing 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 one-story, Type II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Illumination of Means of Egress:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

Based on observation and interview, the facility failed to meet illumination of egress requirements in four of six wings.

Findings include:

Observation on April 30, 2025, at 11:15 a.m., revealed the facility was unable to confirm if the west wing exit signs could be legible in both normal and emergency lighting situations. Interview with the maintenance director revealed the exit signs were glow in the dark, but confirming documentation was unavailable.

Interview with the maintenance director on April 30, 2025, at 10:30 a.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 06/20/2025

The exit signs on west wing have been replaced and documentation obtained confirming the exit signs are glow in the dark.

Nursing Home Administrator to re-educate Maintenance Director on utilizing exit signs that meet illumination of egress requirements when changing or hanging new/additional exit signs and obtaining documentation that states that the exit signs meet requirements.

Nursing Home Administrator will audit all new exit signs to ensure that they do meet illumination of egress requirements and that documentation is on file.

NFPA 101 STANDARD Exit Signage:

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 observation and interview, the facility failed to maintain exit signs in one of over eight corridors.

Findings include:

Observation on April 30, 2025, between 9:39 a.m. and 9:40 a.m., revealed the following exit sign deficiencies:
A. (9:39 a.m.) Basement corridor fire doors, located near the maintenance office, had a missing exit sign;
B. (9:40 a.m.) Basement corridor exit sign, located outside the B-4 storage room, had a missing chevron.

Interview with the maintenance director on April 30, 2025, at 9:40 a.m., confirmed the above deficiencies at the time of the survey.

Plan of Correction - To be completed: 06/20/2025

A new exit sign has been purchased and installed at the basement corridor fire doors, located near the maintenance office.

A new exit sign with chevron has been purchased and installed at the basement corridor exit sign, located outside the B4 storage room.

Nursing Home Administrator to re-educate Maintenance Director on maintaining appropriate placement of exit signs as well as utilizing the appropriate directional signs in each location.

Maintenance director or designee to audit exit sign locations weekly for four (4) weeks to ensure exit signs are appropriately placed and that the signs are appropriate for the direction of the exit.

NFPA 101 STANDARD Fire Alarm System - Installation:

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 - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0341

Based on document review and interview, the facility failed to maintain and inspect the fire alarm system for one of one panel.

Findings include:

1. Document review on April 30, 2025, at 11:35 a.m., revealed that upon installation of the new fire panel in May 2024, the acknowledgement documentation was contradicting and unclear regarding possible deficiencies. The documentation selected Failures and System Deviations from NFPA Standards as well as selecting None. The acknowledgement documentation also listed the "manual trip pressure switch."
2. Observation on April 30, 2025, at 11:35 a.m., revealed the fire alarm panel was in supervised mode.

Interview with the administrator on April 30, 2025, at 11:35 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 06/20/2025

Documentation has been obtained, clearing up the contradicting and unclear notations of possible deficiencies.

Documentation has been obtained, clearing up the notation that the fire alarm panel was in supervised mode.

Nursing Home Administrator to re-educate the Maintenance Director on reviewing post-work reports provided by vendors to ensure documentation is correct according to the Maintenance Director's understanding and contacting the vendor with any questions or concerns.

Nursing Home Administrator to audit vendor post-work reports monthly for three (3) months to ensure Maintenance Director is reviewing reports for possible errors.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on document review and interview, the facility failed to maintain smoke barrier requirements in four of six wings.

Findings include:

Document review on April 30, 2025, at 10:30 a.m., revealed the following smoke/fire damper deficiencies:
A. (10:30 a.m.) East B had two deficient dampers;
B. (10:30 a.m.) East A had one deficient damper;
C. (10:30 a.m.) West C had two deficient dampers;
D. (10:30 a.m.) West A had two deficient dampers.

Interview with the maintenance director on April 30, 2025, at 10:30 a.m., confirmed the smoke/fire damper deficiencies.

Based on observation and interview, the facility failed to maintain smoke barrier construction on two of two building levels.

Findings include:

Observation on April 30, 2025, between 10:09 a.m. and 11:14 a.m., revealed the following deficiencies:
A. (10:09 a.m.) Basement ceiling tiles lacked minor maintenance throughout the basement, with loose, misaligned, cracked, and stained tiles present that could possibly allow smoke to spread throughout the facility. An approximate ten percent of the basement ceiling area was affected during observation;
B. (11:14 a.m.) Main level C wing air handling room had an unsealed wire penetration in the ceiling.

Interview with the maintenance director on April 30, 2025, at 11:14 a.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 06/20/2025

The two deficient dampers on East B, the one deficient damper on East A, the two deficient dampers on West C, and the two deficient dampers on West A have been noted and specified in the maintenance documentation. The facility will obtain quotes to repair and/or replace the deficient dampers.

Noted basement ceiling tiles that lacked minor maintenance have been addressed and/or replaced.

All other basement ceiling tiles have been audited to address any lacking minor maintenance.

The unsealed wire penetration in the ceiling in the Main level C wing air handling room has been sealed.

Nursing Home Administrator to re-educate Maintenance Director on maintain integrity of smoke barriers.

Maintenance Director or designee to audit 20 ceiling tiles as well as Main level C wing air handler room weekly for four (4) weeks to ensure integrity of smoke barriers.

NFPA 101 STANDARD Electrical Systems - Other:

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, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, for one of over twenty electrical connection boxes.

Findings include:

Observation on April 30, 2025, at 11:14 a.m., revealed that the C wing air handling room had an MC wire that was not secured to the cable connector, exposing the wires without the "Metal Clad - MC" protection.

Reference: NFPA 70 - 314.17

Interview with the maintenance director on April 30, 2025, at 11:14 a.m., confirmed the electrical system deficiency.

Plan of Correction - To be completed: 06/20/2025

The MC wire in the C wing air handling room found to be secured to the cable connector, exposing the wires without the "Metal Clad-MC" protection has been secured.

Nursing Home Administrator to re-educate Maintenance Director on maintaining electrical system requirements for electrical connection boxes.

The Maintenance Director or designee will audit the C wing air handler room weekly for four (4) weeks to ensure the integrity of the electrical connection boxes is maintained and no wires are exposed.

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