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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 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.


TWINBROOK 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 May 15, 2024, it was determined that Twinbrook Healthcare and Rehabilitation Center was in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01/EAST - Component: 01 - Tag: 0000

Facility ID #200602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, it was determined that Twinbrook 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 two-story, Type II (000), unprotected, non-combustible 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: MAIN BUILDING 01/EAST - Component: 01 - Tag: 0100

Based on document review, observation, and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

1. Document review on May 15, 2024, at 10:30 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 its 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 (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance director on May 15, 2024, at 10:30 a.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

Based on observation and interview, the facility failed to meet PA Act #45 requirements for carbon dioxide detectors in one of three building components.

Findings include:

2. Observation on May 15, 2024, at 10:47 a.m., revealed boiler room B had a carbon monoxide detector unplugged from the wall and not properly mounted in case of an emergency situation.

Interview with the maintenance supervisor on May 15, 2024, at 10:47 a.m., confirmed the dectector was not mounted correctly at the time of the survey.

Plan of Correction - To be completed: 07/15/2024

1. The Director of Maintenance or designee will obtain updated portable floor plans that include smoke barrier walls, fire barrier walls, exits, rated rooms, and shaft walls.

2. The Nursing Home Administrator or designee will provide education to the Director of Maintenance on the necessity of ensuring that the building has an updated portable floor plan.

3. The drawings for the floor plans will be submitted to the QAPI committee for review and further recommendations at the monthly QAPI meetings.

4. These plans will be obtained by 7/15/2024.

NFPA 101 STANDARD Fire Drills:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01/EAST - Component: 01 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for four of twelve drills.

Findings include:

Document review on May 15, 2024, at 10:55 a.m., revealed the first shift fire drills occurred during the same half hour slot for each of the last four quarters.

Interview with the maintenance supervisor on May 15, 2024, at 10:55 a.m., confirmed the fire drill deficiency at the time of the survey.

Plan of Correction - To be completed: 07/14/2024

1. The Director of Maintenance or designee will check to make sure fire drills are completed at varying times during the 1st shift timeframe.

2. The Director of Maintenance or designee will audit to ensure that the fire drills are completed at varying times on a quarterly basis for 12 months.

3. Results of the audits will be reported to the QAPI committee for review and further recommendations at the monthly QAPI meetings.

4. The changes to the timing of fire drills will be in effect by 7/14/2024.

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/EAST - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electrical system requirements for one of one generator.
Findings include:
Document review on May 15, 2024, at 11:15 a.m., revealed the facility's annual fuel quality sample results failed due to "not enough sample provided to perform accurate gravity analysis."

Interview with the maintenance supervisor on May 15, 2024, at 11:15 a.m., confirmed the fuel quality sample deficiency at the time of the survey.

Plan of Correction - To be completed: 07/14/2024

1. The Director of Maintenance or designee will call Cleveland Brothers contractor to have the annual fuel sample retaken.

2. The Nursing Home Administrator will ensure that the Director of Maintenance or designee follows up and has the fuel sample retaken.

3. Results of the obtained fuel sample will reported to the QAPI committee for review and verification that it is enough to perform accurate gravity analysis at the monthly QAPI meetings.

4. This updated fuel sample will be taken by 7/15/2024.

Initial comments:Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0000

Facility ID #200602
Component 02
South Building

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, it was determined that Twinbrook 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 one-story, Type III (200), unprotected, ordinary building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on May 15, 2024, at 10:30 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 its 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 (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance director on May 15, 2024, at 10:30 a.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

Plan of Correction - To be completed: 07/14/2024

1. The Director of Maintenance or designee will obtain updated portable floor plans that include smoke barrier walls, fire barrier walls, exits, rated rooms, and shaft walls.

2. The Nursing Home Administrator or designee will provide education to the Director of Maintenance on the necessity of ensuring that the building has an updated portable floor plan.

3. The drawings for the floor plans will be submitted to the QAPI committee for review and further recommendations at the monthly QAPI meetings.

4. These plans will be obtained by 7/14/2024.

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: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0363

Based on observation and interview, the facility failed to maintain corridor doors in one of three building components.

Findings include:

Observation on May 15, 2024, between 11:06 a.m. and 11:37 a.m., revealed the following corridor door deficiencies:
A. (11:06 a.m.) West lounge door failed to positively latch in the frame;
B. (11:10 a.m.) South hallway had two resident rooms with garbage storage that prevented the doors from latching;
C. (11:37 a.m.) South hallway shower room had the door held open with a garbage can.

Interview with the maintenance director on May 15, 2024, at 11:37 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 07/14/2024

1. The Director of Maintenance or designee will correct the deficient doors so that trash cans do not need to be used to keep the doors open.

2. The Director of Maintenance or designee will check the doors to ensure they stay open on their own by conducting audits to take place weekly for 4 weeks and then monthly for 3 months.

3. Results of the audits will be reported to the QAPI committee for review and further recommendations at the monthly QAPI meetings.

4. These deficient doors will be corrected by 7/14/2024.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for four of twelve drills.

Findings include:

Document review on May 15, 2024, at 10:55 a.m., revealed first shift fire drills were conducted during the same half hour slot for each of the last four quarters.

Interview with the maintenance supervisor on May 15, 2024, at 10:55 a.m., confirmed the fire drill deficiency at the time of the survey.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electrical system requirements for one of one generator.
Findings include:
Document review on May 15, 2024, at 11:15 a.m., revealed the facility's annual fuel quality sample results failed due to "not enough sample provided to perform accurate gravity analysis."

Interview with the maintenance supervisor on May 15, 2024, at 11:15 a.m., confirmed the fuel quality sample deficiency at the time of the survey.

Initial comments:Name: BLDG 03/SOUTHEAST BUILDING - Component: 03 - Tag: 0000

Facility ID #200602
Component 03
South East Building

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, it was determined that Twinbrook 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 one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: BLDG 03/SOUTHEAST BUILDING - Component: 03 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on May 15, 2024, at 10:30 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 its 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 (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance director on May 15, 2024, at 10:30 a.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to contain the listed items.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: BLDG 03/SOUTHEAST BUILDING - Component: 03 - Tag: 0222

Based on observation and interview, the facility failed to maintain egress doors in one of three building components.

Findings include:

Observation on May 15, 2024, at 12:00 p.m., revealed the emergency exit door, located near room E113, was difficult to open and could possibly slow egress during an emergency.

Interview with the maintenance director on May 15, 2024, at 12:00 p.m., confirmed the door was difficult to open.

Plan of Correction - To be completed: 07/14/2024

1. The Director of Maintenance or designee will correct the door deficiency so it opens easier for quicker and more efficient egress.

2. The Director of Maintenance or designee will conduct audits that will occur weekly for 4 weeks and then monthly for 3 months to ensure that the door will open easier for quicker and more efficient egress.

3. Results of the audits will be reported to the QAPI committee for review and further recommendations at the monthly QAPI meetings.

4. This deficient door will be corrected by 7/14/2024.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: BLDG 03/SOUTHEAST BUILDING - Component: 03 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for four of twelve drills.

Findings include:

Document review on May 15, 2024, at 10:55 a.m., revealed first shift fire drills were conducted during the same half hour slot for each of the last four quarters.

Interview with the maintenance supervisor on May 15, 2024, at 10:55 a.m., confirmed the fire drill deficiency at the time of the survey.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BLDG 03/SOUTHEAST BUILDING - Component: 03 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electrical system requirements for one of one generator.
Findings include:
Document review on May 15, 2024, at 11:15 a.m., revealed the facility's annual fuel quality sample results failed due to "not enough sample provided to perform accurate gravity analysis."

Interview with the maintenance supervisor on May 15, 2024, at 11:15 a.m., confirmed the fuel quality sample deficiency at the time of the survey.

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