Pennsylvania Department of Health
 GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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GLEN BROOK REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  44 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.
GLEN BROOK REHABILITATION AND HEALTHCARE 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 June 18, 2024, at Glen Brook Rehabilitation and Healthcare 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# 281102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 18, 2024, it was determined that Glen Brook Rehabilitation and Healthcare 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible structure, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of one floor.

Findings include:

1. Observation on June 18, 2024, at 11:36 a.m., revealed the North Wing, smoke barrier separation left door required adjustment to latch into frame.


Exit interview with the Facility Administrator and the Director of Maintenance on June 18, 2024, at 12:00 p.m., confirmed the smoke barrier separation door failed to latch.







 Plan of Correction - To be completed: 07/22/2024

K 0374
1. The North Wing smoke barrier separation left door requires adjustment so it can latch to the frame.
2. The North Wing smoke barrier separation left door has been adjusted to ensure the door latches to the frame.
3. The Maintenance manager/Designee will audit other facility doors to ensure doors are properly adjusted.
4. Corrective Action Date: July 22, 2024

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID# 281102
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on June 18, 2024, it was determined that Glen Brook Rehabilitation and Healthcare 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible structure, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices in two locations, affecting one of one floors.

Findings include:

1. Observation on June 18, 2024, between 10:21 a.m., and 10:43 a.m., revealed the following:

a. At 10:21 a.m., Willow Wing, Linen Closet, Near Resident Room 805, failed to latch into frame when tested.

b. At 10:43 a.m., Spruce Wing, Linen Closet, Near Resident Room 405, failed to latch into frame when tested.


Exit interview with the Facility Administrator and the Director of Maintenance on June 18, 2024, at 12:00 p.m., confirmed the door failed to latch into frame when tested.








 Plan of Correction - To be completed: 07/22/2024

K 0223
1 The Willow Wing Linen closet near resident room 805 and the Spruce Wing Linen closet, near resident room 405 failed to latch into the frame when tested.
2. The Willow and Spruce Wing Linen closets specified have been adjusted and are now latching properly.
3. The Maintenance manager/Designee will audit other Linen closet doors to ensure doors are properly latching.
4. Corrective Action Date: July 22, 2024

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser in one of five smoke compartments.

Findings include:

1. Observation on July 18, 2024, at 10:47 a.m., Spruce Wing, revealed that a ABHR dispenser was installed over a call button annunciator in the soiled linen room.

Exit interview with the Facility Administrator and the Director of Maintenance on June 18, 2024, at 12:00 p.m., confirmed the dispenser was installed over the annunciator.








 Plan of Correction - To be completed: 07/22/2024

K 0325
1. The Spruce Wing ABHR dispenser was installed over a call bell annunciator in the soiled linen room.
2. The specified ABHR dispenser was removed and installed in an appropriate location.
3. Maintenance manager/Designee will ensure that ABHR dispensers are installed appropriately.
4. Corrective Action Date: July 22, 2024

NFPA 101 STANDARD Electrical Equipment - 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 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 02 - Component: 02 - Tag: 0919

Based on observation and interview, the facility failed to maintain the proper usage and maintenance of electrical components in one location, affecting one of two floors.

Findings include:
1. Observation on June 18, 2024, at 10:36 a.m., Therapy Room, opening in the wall used for access to camera wiring, lacked a cover plate over the opening.

Exit interview with the Facility Administrator and the Director of Maintenance on June 18, 2024, at 12:00 p.m., confirmed the wiring was exposed.







 Plan of Correction - To be completed: 07/22/2024

K 0919
1. An opening in the Therapy room wall used for access to camera wiring did not have a plate to cover the opening.
2. The opening in the Therapy room wall immediately had a cover plate installed.
3. The Maintenance Manager/Designee will audit other areas to ensure face plates are installed where appropriate.
4. Corrective Action Date: July 22, 2024

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: BUILDING 02 - Component: 02 - Tag: 0923

Based on observation and interview, the facility failed to properly secure oxygen cylinders on one of one floors.

Findings include:

1. Observation on June 18, 2024, at 10:14 a.m., revealed (2) oxygen "E" cylinders, being stored, in the outside oxygen storage (empty) cabinet, were being store on the floor without support.

Exit interview with the Facility Administrator and the Director of Maintenance on June 18, 2024, at 12:00 p.m., confirmed the cylinders were not supported.






 Plan of Correction - To be completed: 07/22/2024

K 0923
1. Two oxygen "E" cylinders in the outside oxygen storage area were stored on the floor without support.
2. The Two oxygen "E" cylinders in the outside oxygen storage area were immediately corrected and stored with support.
3. The Maintenance Manager/Designee will audit the outside oxygen storage area to ensure oxygen "E" tanks are stored correctly.
4. Corrective Action Date: July 22, 2024




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