Pennsylvania Department of Health
ZERBE SISTERS NURSING CENTER, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ZERBE SISTERS NURSING CENTER, INC. - 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 March 19, 2024, at Zerbe Sisters Nursing Center, Inc., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 1 - Component: 01 - Tag: 0000

Facility ID# 260402
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on March 19, 2024, it was determined that Zerbe Sisters Nursing Center, Inc., 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 III (200), unprotected ordinary structure, with a basement and unused attic space, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting seven of seven smoke compartments within the component.

Findings include:

1. Observation on March 19, 2024, between 9:30 AM and 1:00 PM, revealed the building exceeds the maximum allowable story height, for a Type III (200), unprotected ordinary structure.

Interview at the time of the exit conference with the Maintenance Manager and Maintenance Supervisor on March 19, 2024, at 1:30 PM, confirmed the building construction type is not allowed in health care.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide at least two exits, remote from one another, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on March 19, 2024, between 9:30 AM and 1:00 PM, revealed the facility lacked two exits remote from each other, in the following locations:

a. 9:30 AM, 2nd floor Annex.
b. 1:00 PM, basement.

Interview at the time of the exit conference with the Maintenance Manager and Maintenance Supervisor on March 19, 2024, at 1:30 PM, confirmed the component lacked two acceptable exits in the Annex and the Basement.

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: BUILDING 1 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed maintain the automatic sprinkler system to be free of obstructions, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on March 19, 2024, between 11:15 AM and 11:50 AM, revealed sprinkler heads covered with debris, at the following locations:

a. 11:15 AM, basement, Laundry Room, wash area, 4 sprinkler heads;
b. 11:18 AM, basement, Laundry Room, dry area, 3 sprinkler heads;
c. 11:50 AM, Kitchen, above main food station, 4 sprinkler heads.

Interview at the time of the exit conference with the Maintenance Manager and Maintenance Supervisor on March 19, 2024, at 1:30 PM, confirmed debris covering sprinkler heads.

Plan of Correction - To be completed: 04/16/2024

This POC does not constitute an admission of or agreement with the alleged facts and conclusions set forth on the survey report. It is prepared and executed solely as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements.

1. Identified sprinkler heads covered with debris in the Laundry and Kitchen areas have been cleaned to ensure they are free of obstruction.

2. Maintenance staff shall be educated by the Maintenance Director on sprinkler head maintenance requirements.

3. Sprinkler heads in the problem areas identified shall be added to the monthly maintenance checks for the next three months and quarterly thereafter. Any additional debris-covered sprinkler heads identified during checks shall be cleaned as per NFPA 13 guideline using canned air.

4. Maintenance Director/designee shall report status of the monthly sprinkler head checks in monthly QAPI meeting for review and recommendation.

NFPA 101 STANDARD Electrical Equipment - Other:

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 - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)

Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment, in one of seven smoke zones within the component.

Findings include:

1. Observation on March 19, 2024, at 11:40 AM, revealed two electrical junction boxes above the ceiling, at the smoke barrier doors, in the North Hall, at Mount Vista, lacked cover plates.

Interview at the time of the exit conference with the Maintenance Manager and Maintenance Supervisor on March 19, 2024, at 1:30 PM, confirmed the junction box covers were missing.

Plan of Correction - To be completed: 04/16/2024

This POC does not constitute an admission of or agreement with the alleged facts and conclusions set forth on the survey report. It is prepared and executed solely as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements.

1. The identified junction boxes above the ceiling lacking cover plates have been repaired by fire system contractor.

2. Maintenance staff shall be educated on the requirement to properly maintain electrical wiring and equipment.

3. Checking for junction box cover plates above the ceiling tile shall be added to maintenance's monthly inspection list and monitored by Maintenance Director/Designee for next three months and quarterly thereafter.

4. An inspection form shall be developed for use for specified vendor work completed above ceiling tile that is to be signed off by a facility representative prior to closing up the tile to ensure safety and compliance standards are being met.

5. Maintenance Director/Designee shall report results of the monthly checks in monthly QAPI meeting for review and recommendation.

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