Nursing Investigation Results -

Pennsylvania Department of Health
PROMEDICA TOTAL REHAB + (EXTON)
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PROMEDICA TOTAL REHAB + (EXTON)
Inspection Results For:

There are  7 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.
PROMEDICA TOTAL REHAB + (EXTON) - 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 25, 2022, at Promedica Total Rehab + (Exton), it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID #24600201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 25, 2022, it was determined that Promedica Total Rehab + (Exton) 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 (111), protected noncombustible structure, with a partial basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
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 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signage, affecting one of ten smoke compartments within the component.

Findings include:

1. Observation on May 25, 2022, at 1:40 PM, revealed the exit sign in the 1st floor Admin Offices directed egress from the corridor to within the Admin Office suite. There is no exterior egress from within this suite.

Interview with the Administrator on May 25, 2022, at 1:40 PM, confirmed the exit sign did not direct egress to an exit.




 Plan of Correction - To be completed: 07/20/2022

EXIT SIGN WAS REMOVED. COMPLETED MAY 3, 2022
NFPA 101 STANDARD Fire Alarm System - Installation: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.
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 - Component: 01 - Tag: 0341

Based on observation and interview, it was determined the facility failed to install a complete fire alarm system, affecting the entire component.

Findings include:

1. Observation on May 25, 2022, at 1:30 PM, revealed there was not a fire alarm pull station within five feet of the single exterior exit door at the 1 West Sitting Area.

Interview with the Administrator on May 25, 2022, at 1:30 PM, confirmed the lack of a pull station.


2. Observation on May 25, 2022, at 1:45 PM, revealed there was not a fire alarm pull station within five feet of the single exterior exit door, by the Main Entrance.

Interview with the Director of Maintenance on May 25, 2022, at 1:45 PM, confirmed the lack of a pull station.




 Plan of Correction - To be completed: 07/20/2022

New pull stations will be installed by a certified contractor. To be completed by 7-10-22.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain a supply of spare sprinkler heads and the associated wrench, affecting the entire component.

Findings include:

1. Observation on May 25, 2022, at 12:50 PM, revealed the facility lacked a supply of sidewall oriented sprinkler heads, as well as a sprinkler head wrench.

Interview with the Administrator on May 25, 2022, at 12:50 PM, confirmed the lack of spare sprinkler heads and the associated wrench.



 Plan of Correction - To be completed: 07/20/2022

There will be a new sprinkler wrench and sprinkler heads ordered. To be completed by 7-20-22.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to verify monthly inspections of portable fire extinguishers had been completed, affecting the entire component.

Findings include:

1. Review of documentation on May 25, 2022, between 10:00 AM and 12:00 PM, revealed the facility failed to provide documentation verifying portable fire extinguishers within the facility had been subjected to monthly inspections, between the annual inspection in January 2022, and April 29, 2022.

Interview with the Administrator on May 25, 2022, at 12:00 PM, confirmed the facility could not verify the owner's quick check inspection had been performed after the annual inspection in January.




 Plan of Correction - To be completed: 07/20/2022

The facility fire extinguishers will be inspected each month going forward.

Fire extinguisher inspections will be implemented into monthly maintenance schedule to ensure inspections completed monthly.


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: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting two of ten smoke compartments within the component.

Findings include:

1. Observation on May 25, 2022, at 12:15 PM, revealed the door to the Telcom Room, next to Resident Room 116, failed to positively latch within the door frame.

Interview with the Administrator on May 25, 2022, at 12:15 PM, confirmed the door did not latch within the frame.


2. Observation on May 25, 2022, at 12:51 PM, revealed the single door to the Kitchen, across from the Laundry, failed to positively latch within the door frame.

Interview with the Administrator on May 25, 2022, at 12:51 PM, confirmed the door did not latch within the frame.




 Plan of Correction - To be completed: 07/20/2022

The doors will be adjusted to close and latch into frame. Maintenance completed on 6-1-22.

A door audit will be completed monthly by maintenance personnel to ensure doors positively latch throughout the center.

Results of the audit will be shared monthly at the quality assurance performance improvement committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the unobstructed closing of smoke barrier doors, affecting one of ten smoke compartments within the component.

Findings include:

1. Observation on May 25, 2022, at 1:14 PM, revealed a blood pressure machine stored within the path of the cross-corridor smoke barrier doors, by 2nd floor Resident Room 223.

Interview with the Administrator on May 25, 2022, at 1:14 PM, confirmed the obstructed smoke barrier doors.



 Plan of Correction - To be completed: 07/20/2022

Blood pressure machine removed at time of survey. Completed on 5-25-22.

Center staff will be in-serviced to ensure no items or equipment are stored within the path of the cross-corridor smoke barrier doors.

An audit will be completed monthly by maintenance personnel to ensure items or equipment are not stored in path of cross-corridor smoke barrier doors.

Results of the audit will be shared monthly at the quality assurance improvement committee.


NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers, affecting one of ten smoke compartments within the component.

Findings include:

1. Observation on May 25, 2022, at 12:55 PM, revealed a three-to-one receptacle multiplier, in use, in the Dining Services Room, in the Kitchen.

Interview with the Administrator on May 25, 2022, at 12:55 PM, confirmed the use of a receptacle multiplier.




 Plan of Correction - To be completed: 07/20/2022

The receptacle multiplier was removed during the inspection. Completed 5-25-22.

Center staff will be in-serviced that receptacle multipliers are not permitted for use within facility.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port