Nursing Investigation Results -

Pennsylvania Department of Health
CLIVEDEN NURSING AND REHABILITATION CENTER
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
CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  40 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.
CLIVEDEN 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 January 21, 2020, it was determined that Cliveden Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include a plan to ensure the emergency generator provides continuous power during an emergency, affecting the entire facility.

Findings include:

1. Document review on January 21, 2020, at 2:15 pm, revealed the facility's Emergency Preparedness Plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event their primary fuel supplier is unavailable during an emergency.
Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 p.m., confirmed the documentation was not available.





 Plan of Correction - To be completed: 03/16/2020

Facility added a written plan to the Emergency Preparedness Plan for a secondary fuel supplier for the facility's emergency generator in the event our primary fuel supplier is unavailable during an emergency.
Maintenance Director or designee will audit the Emergency Preparedness plan annually to ensure emergency generator contracts are up to date.
Results of audit will be presented at QAPI annually, Administrator to monitor for ongoing compliance.

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


Facility ID# 330402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 21, 2020, it was determined that Cliveden 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 (000), unprotected non-combustible structure, with a basement, 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: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire facility.

Findings include:

1. Observation and document review on January 21, 2020, between 8:30 a.m. and 3:00 p.m, revealed the facility was a three story, Type II (000), unprotected ordinary construction building, with a basement, that was fully sprinklered. The building height exceeds the maximum allowance for this construction type by two stories.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 p.m., confirmed the building construction lacks a fire resistance rating.





 Plan of Correction - To be completed: 03/16/2020

building will utilize 5 year limited time waiver.Facility requests the Department of Health Division of Life Safety conducts the FSES inspection and provides an updated FSES.
NFPA 101 STANDARD Means of Egress - General: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.
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 ensure that exits are readily accessible and exit access is not blocked, affecting one of four stair towers within this component.

Findings include:

Observation made on January 21, 2020, at 1:20 p.m., revealed that 1st floor east wing stair tower access door, by room 105, was blocked from access due to a patient lift being placed in front of the door.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 p.m., confirmed the door was not free of all obstructions or impediments to full instant use.





 Plan of Correction - To be completed: 03/16/2020

Patient lift was removed from blocking the east wing stair tower access door.
Other exit doors in facility were checked to ensure that they were not blocked by patient lifts.
Staff educated that exits are to be readily accessible and continuously maintained free of all obstructions for full use in case of an emergency.
Maintenance staff, supervisor or designee will audit exit doors 3x week for 3 months to ensure they are free from obstruction.
Maintenance Director will report Results of audit to the Administrator at the safety committee monthly x 3. Administrator or designee will monitor monthly at QAPI for ongoing compliance.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain two of its four stair towers within the facility.

Findings include:

1. Observation on January 21, 2020, at 11:08 am, revealed an unsealed penetration by a telephone wire above the ceiling on the 3rd floor of the South stair tower.

Interview with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the penetration.

2. Observation on January 21, 2020, at 11:16 am , revealed a burned out light fixture in the North stair tower on the landing above the 3rd floor leading to the roof.

Interview at the exit conference Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the burnt out fixture.






 Plan of Correction - To be completed: 03/16/2020

Unsealed penetration by telephone wire above the ceiling on the 3rd floor of south tower were sealed according to the UL system number C-AJ-3154, which is an approved penetration fire stop system.
Light fixture in north stair tower was repaired so that it illuminated properly.
Other stair towers in facility where checked to ensure that they were maintained in accordance with NFPA 10
Maintenance staff educated on stairways and smokeproof enclosures to ensure no penetrations and proper functioning lighting. Staff educated according to the UL system number C-AJ-3154, which is an approved penetration fire stop system.
Maintenance staff, or designee will audit stairways 3x a week for 3 months to ensure light fixtures are in place and no penetrations present.
Maintenance Director will report Results of audit to the Administrator at the safety committee monthly x 3. Administrator or designee will monitor monthly at QAPI for ongoing compliance.

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 ensure sprinklers were free of debris on one of four levels of the facility.

Findings include:

1. Observation on January 21, 2020, at 1:55 pm, revealed excessive debris on the sprinkler in the dryer room in the basement.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the excessive debris.





 Plan of Correction - To be completed: 03/16/2020

The debris on the sprinkler in the dryer room in the basement was cleaned.
Other sprinkler heads in the building checked to ensure that sprinkler heads were cleaned.
Maintenance staff educated related to the inspection of sprinkler heads.
Maintenance staff or designee will audit sprinkler heads monthly to ensure they are free from debris.
Maintenance Director will report the results of the audit to the Administrator at the safety committee meeting monthly x3. Administrator or designee will monitor monthly at QAPI for ongoing compliance.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were inspected, affecting one of seven smoke compartments within the facility.

Findings Include:

Observation made on January 21, 2020, at 1:40 pm, 1st floor, revealed fire extinguisher located at the base of the South wing was missing a monthly quick check inspection for January of 2020.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the missing monthly quick check.





 Plan of Correction - To be completed: 03/16/2020

Fire extinguisher on base of south wing 1st floor was quick checked and signed off on.
All other fires extinguishers were inspected to ensure that they were quick checked.
Maintenance staff educated on the NFPA 10 related to the standard of maintaining portable extinguishers.
Maintenance staff, or designee will audit monthly fire extinguishers are quick checked.
Maintenance Director or designee will report the results of the audit to the Administrator at the safety committee meeting monthly x3. Administrator or designee will monitor monthly at QAPI for ongoing compliance

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were not impeded from closing and positively latching and corridor doors resist the passage of smoke in three of seven smoke compartments within this facility.

Findings include:

1. Observation on January 21, 2020, between 10:30 am and 10:55 am, revealed doors that had a gap and were not resistant to the passage of smoke in the following locations:

a. 10:30 am, 3rd floor, east wing Resident Lounge.
b. 10:55 am, 3rd floor, west wing Resident Lounge.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the gap in the doors.

2. Observation on January 21, 2020, at 1:58 pm, revealed the Trash Room door in the basement was binding on the door stop and would not self-close.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the binding door.





 Plan of Correction - To be completed: 03/16/2020

These doors which were noticed with a gap was fixed and repaired in order to not allow the passage of smoke. 3rd floor east wing resident lounge, 3rd floor west wing resident lounge. Astragals were placed on the hallway side of the lounge doors to span the gap between the two doors for each lounge thus providing a barrier to smoke between the doors.
The trash room door which was binding on the door stop and would not self-close was repaired.The basement trash room door's door stop removed to prevent binding and prohibiting self closing.

All other lounge doors and trash room doors checked to ensure that a smoke barrier is maintained.
Maintenance staff educated on NFPA 101 corridor doors. Staff will audit smoke barrier weekly x 3months to ensure smoke barrier maintained.
Maintenance Director or designee will audit smoke barrier doors monthly x 3 and report the results to the Administrator at the safety committee meeting. Administrator or designee will monitor monthly at QAPI for ongoing compliance.

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 Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain that smoke barrier walls were free of unsealed penetrations in three of seven smoke compartments within the facility.

Findings include:

1. Observation on January 21, 2020, between 11:00 am and 1:18 pm, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 11:00 am, 3rd floor west wing inside room 329.
b. 11:04 am, 3rd floor, resident room 320, above the ceiling.
c. 12:45 pm, 2nd floor, resident room 220, above the ceiling.
d. 12:46 pm, 2nd floor, resident room 229, above the ceiling.
e. 1:16 pm, 1st floor, resident room 130, above the ceiling.
f. 1:18 pm, 1st floor, resident room 120, above the ceiling.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the above penetrations.






 Plan of Correction - To be completed: 03/16/2020

These smoke barrier walls with penetrations above the ceiling were fixed and repaired in order to not allow the passage of smoke. Room 329,320,220,229,130,120 penetrations were repaired according to the UL system number C-AJ-3154, which is an approved penetration fire stop system.
Other rooms checked to ensure that a smoke barrier is maintained above the ceiling.
Maintenance staff educated on barrier walls being free from penetration and the proper smoke barrier. Maint. Staff will audit smoke barrier weekly x 3 months to ensure smoke barrier maintained.
Maintenance Director or designee will audit smoke barrier walls monthly x 3 to ensure penetrations are sealed with the UL system number C-AJ-3154, which is an approved penetration fire stop system and report the results to the Administrator at the safety committee meeting. Administrator or designee will monitor monthly at QAPI for ongoing compliance.

NFPA 101 STANDARD Elevators: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.
Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.)
19.5.3, 9.4.2, 9.4.3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0531

Based on observation and interview, it was determined the facility failed to maintain the service elevator shaft, affecting one of two elevator shafts in the facility.

Findings include:

1. Observation on January 21, 2020, at 2:01 pm, revealed an unsealed penetration of the shaft behind the elevator call buttons on the ground level.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the unsealed penetration.






 Plan of Correction - To be completed: 03/16/2020

Penetration of the shaft behind the elevator call buttons on ground level was sealed with the appropriate fire rated material. according to the UL system number C-AJ-3154, which is an approved penetration fire stop system.

Elevators in facility was inspected to ensure no other open penetrations existed.
Maintenance Director or designee to audit elevator penetrations monthly x 3 to ensure penetrations filled according to the UL system number C-AJ-3154, which is an approved penetration fire stop system. Results of audit to be presented a safety meeting. Administrator or designee will monitor monthly at QAPI for ongoing compliance.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:This is a less serious (but not lowest level) 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 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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined that the facility failed to maintain its Laundry and Trash chutes, affecting the entire facility.

Findings include:

1. Observation on January 21, 2020, at 10:50 am, revealed the 3rd floor, west wing linen chute door did not positively latch.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the non-latching door.

2. Observation on January 21, 2020, between 1:51 pm and 1:58 pm, revealed trash and linens blocking the fire doors at the bottom of the chutes in the following locations:

a. 1:51 pm, basement, soiled linen chute.
b. 1:58 pm, basement, trash chute.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the blocked chutes.





 Plan of Correction - To be completed: 03/16/2020

The west wing linen chute door was fixed so that it positively latched.
The trash and linen was removed from the bottom of the chutes in the basement soiled linen and trash chute.
Other rooms linen chute doors where checked to ensure positive latch and that they were clear from soiled linen and/ or trash.
Housekeeping and maintenance staff educated on positive latching chute doors and soiled linen and trash not blocking chutes.
Housekeeping Director or designee will audit chute doors monthly x 3 and report the results to the Administrator at the safety committee meeting. Administrator or designee will monitor monthly at QAPI x 4 for ongoing compliance.

NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of rated door assemblies, affecting one of four levels within the facility.

Findings include:

1. Observation made on January 21, 2020, at 1:45 pm, 1st Floor, revealed the North stair tower door was missing a fire rating label.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the missing label.





 Plan of Correction - To be completed: 03/16/2020

1st floor north side tower door will be evaluated a labeled with the appropriate fire rating label.
Other doors audited to ensure that fire rating labels are present
Maintenance Director or designee to audit floors 2x a year to and report the results to Administrator at the safety committee meeting. Administrator or designee will monitor monthly at QAPI x 3 for ongoing compliance.

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 that electrical wiring was protected during two instances on one of four levels within the facility.

Findings include:

1. Observation on January 21, 2020, between 1:21 pm and 1:34 pm, revealed open junction boxes in the following locations:

a. 1:21 pm, 1st floor, near the West stair tower, a junction box without a cover plate above the ceiling.
b. 1:34 pm, 1st floor, near the South stair tower, a junction box missing a knock out above the ceiling.

Interview at the exit conference with the Director of Nursing and the Director of Maintenance on January 21, 2020, at 3:00 pm, confirmed the open junction boxes.





 Plan of Correction - To be completed: 03/16/2020

Open junction boxes in south and west stair towers above the ceiling where covered with a cover plate.
Other junction boxes in facility stair towers checked to ensure that they have a cover plate.
Maintenance staff educated on having covers on junction boxes.
Maintenance Director or designee to audit junction boxes in stair towers above the ceilings monthly x 3 and report the results to the Administrator at the safety committee meeting. Administrator or designee will monitor monthly at QAPI x 4 for ongoing compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) 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 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 Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to maintain required components of the Essential Electrical System (ESS), affecting the entire facility.

Findings include:

1. Observation made on January 21, 2020, between 1:30 p.m. and 2:00 p.m., revealed the outdoor emergency generator lacked a labeled remote manual stop station for diesel-fired generator.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on January 21, 2020, at 3:00 pm, confirmed the emergency generator deficiency.







 Plan of Correction - To be completed: 03/16/2020

Vendor contacted to install a labeled remote manual stop station for diesel-fired generator.
Maintenance Director or designee will check function of button quarterly.
Results of audit to be reported to Administrator at QAPI monthly x 3.


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