Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LUZERNE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

There are  37 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LUZERNE - 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 11, 2022, at Kadima Rehabilitation and Nursing at Luzerne, 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# 283802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 11, 2022, it was determined that Kadima Rehabilitation and Nursing at Luzerne, 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 V (000), unprotected, wood-frame building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain common walls, affecting one of three smoke compartments.

Findings include:

1. Observation on May 11, 2022, at 11:05 a.m., revealed the common wall doors with the Administration Building did not close and latch.

Exit interview with the facility administrator and facility representative #1 on May 11, 2022, at 11:50 a.m., confirmed the doors did not close and latch.




 Plan of Correction - To be completed: 05/20/2022

1. The common wall doors with the Administration Building were adjusted to close and latch properly.
2. A facility wide audit was completed and no other doors in need of adjustment were identified.
3. The maintenance director was re-educated on ensuring maintenance of common walls affecting smoke compartments.
4. The NHA & Maintenance Director or designees will conduct an audit of the common wall doors with the Administration Building weekly x4 then monthly x2 to ensure that they close and latch properly. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas, affecting one of three smoke compartments.

Findings include:

1. Observation on May 11, 2022, at 10:20 a.m., revealed sheetrock was removed and not replaced from inside the Soiled Linen room.

Exit interview with the facility administrator and facility representative #1 on May 11, 2022, at 11:50 a.m., confirmed the lack of wall covering.




 Plan of Correction - To be completed: 05/20/2022

1. The penetration was sealed.
2. A facility wide audit was completed, and no other penetrations were identified.
3. The maintenance director was re-educated on maintaining hazardous areas/ sealing penetrations.
4. The NHA completed a onetime audit of the unsealed penetration area to ensure it was sealed. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.

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 doors, affecting two of three smoke compartments.

Findings include:

1. Observation on May 11, 2022, at 10:10 a.m., revealed the smoke barrier doors located near resident room #12 could not close completely when released from the hold open devices.

Exit interview with the facility administrator and facility representative #1 on May 11, 2022, at 11:50 a.m., confirmed the doors could not close.




 Plan of Correction - To be completed: 05/20/2022

1. The smoke barrier doors located near resident room #12 were adjusted to close completely when released from the hold open devices.
2. A facility wide audit was completed and no other doors in need of adjustment were identified.
3. The maintenance director was re-educated on ensuring maintenance of common walls affecting smoke compartments.
4. The NHA & Maintenance Director or designees will conduct an audit of the smoke barrier doors located near resident room #12 weekly x4 then monthly x2 to ensure that they close completely when released from the hold open devices. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.


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