Nursing Investigation Results -

Pennsylvania Department of Health
FAIRVIEW NURSING AND REHABILITATION CENTER
Building Inspection Results

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FAIRVIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

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FAIRVIEW NURSING 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 25, 2022, at Fairview Care Center of Bethlehem Pike, 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# 320402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 25, 2022, it was determined Fairview Nursing 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 three-story, Type II (222), fire resistive construction, which is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0161
Based on obseration and interview it was determined the facility failed to maintain construction requirements on one of three floors.

Findings include;

1. Observation on May 25, 2022, at 10:50 am revealed the fire protection coating was missing from approximatley 5 feet of a structural steel beam within the 2nd floor elevator equipment room.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the fire protection coating was missing.



 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Approved Fire Coating was placed on exposed portion of structural steel beam of 2nd floor elevator room.
2. Other elevator rooms were checked to ensure no exposure on steel beams.
3. Maintenance staff re-educated on importance of fire coating to steel beams.
4. Maintenance staff or designee will audit elevator rooms to ensure no exposure of steel beams monthly x3.

NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211
Based on observation and interview it was determined the facility failed to maintain corridor width in one location on one of three floors.

Findings include:

1. Observation on May 25, 2022, at 11:10 am revealed a stationary chair being stored in the corridor outside room 137 on the 1st floor.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the chair was not affixed in any way and was being stored.



 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Stationary chair outside room 137 has been removed.
2. Other corridors checked to ensure stationary chairs were affixed to the wall or removed.
3. Maintenance staff re-educated to have stationary chairs affixed to walls.
4. Maintenance staff or designee will audit corridors to ensure stationary chairs are affixed to wall monthly x3.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311
Based on observation and interview it was determined the facility failed to maintain the required fire resistance rating of stair tower doors in location in one of three stair towers.

Findings include:

1. Observation on May 25, 2022, at 10:08 am revealed the 3rd floor door to stair tower P3 had empty screw holes in the face of the door from removed hardware.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the open holes on the face of the door.




 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Screw holes to P3 stair tower door were re-inserted.
2. Other stair tower doors have been checked to ensure no empty screw holes.
3. Maintenance staff re-educated on requirement of screw holes being filled.
4. Maintenance staff or designee will audit stair tower doors to ensure no empty screw holes monthly x3.

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 area doors on two of three floors.

Findings include;

1. Observation on May 25, 2022, 9:45 am and 11:25 am revealed the following;

a. At 9:45 am the door into the 3rd floor laundry had excessive gaps between the face of the door and the frame.
b. At 11:05 am the elevator room door on the 1st floor was not smoke tight while latched in the frame.
c. At 11:25 am the dock door into the kitchen was being held open by a magnet that was hanging from it's electrical wiring.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the hazardous area door issues.


 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. A. Door gaps into third floor laundry have been filled.
B. First floor elevator room door is now smoke tight while latched to frame.
C. Kitchen door magnet re-affixed to wall to not hang from electrical wiring.
2. Maintenance staff re-educated to ensure that are no door gaps; that doors shall be smoke tight while latched; and door magnets should be affixed to walls.
3. Maintenance staff or designee will audit gaps in laundry doors; elevator door rooms are smoke tight while latched to frame; and that door magnets are affixed to wall monthly x3.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview it was determined the facility failed to maintain the sprinkler system on one of three floors.

Findings include;

1. Observation May 25, 2022, at 10:30 am revealed large sections of ceiling tile missing from the 3rd floor laundry.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the missing ceiling tile could delay sprinkler activation.


 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Ceiling tiles on 3rd floor laundry have been replaced.
2. Maintenance staff re-educated on importance of maintaining all ceiling tiles.
3. Maintenance staff or designee will audit laundry room ceiling tiles to make sure all are properly placed monthly x3.


NFPA 101 STANDARD Corridor - Doors: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.
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 01 - Component: 01 - Tag: 0363
Based on observation and interview it was determined the facility failed to maintain one of approximatley seventy-five corridor doors inspected.

Findings include;

1. Observation on May 25, 2022, at 10:45 am revealed the door to resident room 247. 2nd floor was not smoke tight along the top after latching in the frame.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the door lacked smoke tight integrity.



 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Room 247 door has been fixed to be smoke tight while latching.
2. Maintenance staff re-educated on importance having doors be smoke tight.
3. Maintenance staff or designee will audit random room doors to ensure they are smoke tight monthly x3.

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 01 - Component: 01 - Tag: 0374

Based on observation and interview it was determined the facility failed to maintain smoke barrier doors affecting two of six smoke compartments.

Findings include;

1. Observation on May 25, 2022, at 11:20 am revealed the smoke barrier doors on the 1st floor near the administrator office lacked a coordinator and could not close smoke tight when released for the hold open magnets.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the doors were installed with an astragal and lacked a coordinator.



 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. 1st floor barrier doors coordinator repaired to function correctly.
2. Other barrier doors checked to ensure all coordinators function properly.
3. Maintenance staff re-educated on importance of coordinators on barrier doors.
4. Maintenance staff or designee will audit barrier doors to ensure the coordinators are functioning properly monthly x3.

NFPA 101 STANDARD Electrical Systems - 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 Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911
Based on observation and interview it was determined the facility failed to maintain electrical systems on one of three floors.

Findings include;

1. Observation on May 25, 2022, at 11:08 am revealed the electrical panel in the exit access corridor near the nurse station on the 1st floor was unlocked.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the electrical panel was not secured from unauthorized access.

2. Observation on May 25, 2022, at 11:15 am revealed an electrical outlet within 6 feet of the hand wash sink in the T1 shower room, on the 1st floor was not ground fault protected.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the electrical outlet was not GFCI protected.



 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Electrical panel near 1st floor nurses station has been locked. Outlet in P1 shower room is now ground fault protected.
2. Other electrical panels have been checked to ensure they are locked. Other shower room outlets have been checked to make sure they are ground fault protected if required.
3. Maintenance staff re-educated on importance of electrical panels being locked and shower room outlets being ground fault protected when required.
4. Maintenance staff or designee will audit electrical panels to ensure they are locked and that shower room outlets are ground fault protected when required monthly x3.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - 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 01 - Component: 01 - Tag: 0920
Based on observation and interview it was determined the facility failed to monitor for the unauthorized use of extension cords on two of three floors.

Findings include:

1. Observation between 10:05 am and 11: am on May 25, 2022, revealed miscellaneous small appliances were being powered by extension cords in the following locations;

a. At 10:05 am, Resident room 337, 3rd floor.
b. At 10:35 am, Resident room 230, 2nd floor.
c. At 11:00 am, PT unit managers office, 2nd floor.

Interview at the time of the exit conference with the administrator and regional facility representative on May 25, 2022, at 12:00 pm confirmed the use of extension cords.


 Plan of Correction - To be completed: 07/05/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
1. Room 337, 230, and P2 Unit Manager office have had extension cords removed.
2. Other rooms and offices checked to ensure no extension cords.
3. Maintenance staff re-educated to ensure no extension cords are present.
4. Maintenance staff or designee will audit random rooms and offices to ensure no extension cords are present monthly x3.


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