Pennsylvania Department of Health
LIBERTY POINTE REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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LIBERTY POINTE REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  41 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.
LIBERTY POINTE 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 December 28, 2023, at Liberty Pointe 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 (STATION 4 , 5, AND DIALYSIS) - Component: 01 - Tag: 0000


Facility ID# 331402
Component 01
Station 4, 5, and Dialysis Unit

Based on a Medicare/Medicaid Recertification Survey completed on December 28, 2023, it was determined Liberty Pointe Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 V(III), protected wood frame building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 (STATION 4 , 5, AND DIALYSIS) - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility.

Findings Include:

Document review on December 28, 2023, at 8:15 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed accurate floor plans were not available.




 Plan of Correction - To be completed: 02/06/2024

Floor plans were updated to include Smoke Barrier Walls (Outside wall to outside wall), Fire Barrier Walls (2-hour walls), Horizontal Exits, Rated Rooms (Storage rooms, Soiled Utility rooms, designated medical gas rooms), Required exits & Shaft walls.

Administrator Responsible.

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 (STATION 4 , 5, AND DIALYSIS) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler systems, affecting one of four levels in the component.

Findings include:

Observation on December 28, 2023, at 9:45 a.m., revealed, in the basement Laundry, excessive debris on the sprinklers.

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed the debris on the sprinklers.



 Plan of Correction - To be completed: 02/06/2024

Sprinklers in the laundry department were cleaned from debris.
Maintenance team to be educated on the NFPA 101 Sprinkler System requirements & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.
Director of Maintenance to monitor.

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 (STATION 4 , 5, AND DIALYSIS) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of four levels in the component.

Findings include:

Observation on December 28, 2023, at 10:42 a.m., revealed, on the third floor, an open penetration by a data wire, which was above the smoke barrier doors near resident room 305.

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed the open penetration.



 Plan of Correction - To be completed: 02/06/2024

Open penetration above the smoke barrier near room 305 on the third floor was repaired using a stop gap penetration system.

Maintenance team to be educated on the smoke barrier requirements & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.

Director of Maintenance to monitor.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 (STATION 4 , 5, AND DIALYSIS) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of four levels in the component.

Findings include:

Observation on December 28, 2023, at 10:13 a.m., revealed, on the first floor, a mop and a bucket stored within three feet of the electrical panels in Environmental Storage. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m, confirmed the improper storage in front of the electrical panels.




 Plan of Correction - To be completed: 02/06/2024

The mop bucket on the first floor by the environmental storage was immediately removed.
Housekeeping team to be educated on the 3 ft. depth clearance requirement in front of electrical equipment & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.
Director of Maintenance to monitor.

Initial comments:Name: BUILDING 02 (1966 BUILDING) - Component: 02 - Tag: 0000


Facility ID# 331402
Component 02
1966 Building

Based on a Medicare/Medicaid Recertification Survey completed on December 28, 2023, it was determined Liberty Pointe Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 four story, Type II (222), fire resistive building, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Egress 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.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: BUILDING 02 (1966 BUILDING) - Component: 02 - Tag: 0222

Based on observation and interview, it was determined the facility failed to ensure egress doors with delayed-egress locking systems had required indicating signage displayed on the doors, affecting one of four levels in the component.
Findings include:
1. Observation on December 28, 2023, at 9:59 a.m., revealed, in the basement, the delayed-egress door by dialysis lacked signage stating:
"PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS "
Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed the door lacked the required signage.




 Plan of Correction - To be completed: 02/06/2024

Signage for the dialysis door was corrected.

Maintenance team to be educated on the egress doors requirements & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.

Maintenance to monitor.

NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: BUILDING 02 (1966 BUILDING) - Component: 02 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signage, affecting one of four levels in the facility.

Findings include:

Observation on December 28, 2023, at 10:18 a.m., revealed, on the second floor, the exit sign above the smoke barrier doors near the Deck was broken.

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed the broken exit sign.



 Plan of Correction - To be completed: 02/06/2024

Exit sign above smoke barrier near smoking deck was replaced.

Maintenance team to be educated on the exit signage requirements & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.

Maintenance to monitor.

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: BUILDING 02 (1966 BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of four levels in the component.

Findings include:

Observation on December 28, 2023, at 9:50 a.m., revealed, in the basement, an open penetration by data wires above the smoke barrier doors.

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed the open penetration.



 Plan of Correction - To be completed: 02/06/2024

Open penetration above the smoke barrier doors in the basement was repaired using a stop gap penetration system.

Maintenance team to be educated on the smoke barrier requirements & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.

Director of Maintenance to monitor.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
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: BUILDING 02 (1966 BUILDING) - Component: 02 - Tag: 0541

Baed on observation and interview, it was determined the facility failed to maintain the fire resistance of rubbish chutes, affecting one of four levels in the component.

Findings include:

Observation on December 28, 2023, at 10:01 a.m., revealed, in the Basement, the rubbish chute door lacked a fusible link.

Exit Interview with the Administrator and the Director of Maintenance, on December 28, 2023 at 11:00 a.m., confirmed the lack of fusible link.



 Plan of Correction - To be completed: 02/06/2024

Fusible link for basement chute door was repaired.

Maintenance team to be educated on the Rbbish Chutes requirements & will be monitored monthly for 2 months. Findings will be brought to the QAPI committee.

Director of Maintenance to monitor.


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