Pennsylvania Department of Health
ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI - 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 February 27, 2024, at Elan Skilled Nursing and Rehab, a Jewish Senior Life Community, 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 #360402
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined the Elan Skilled Nursing and Rehab, a Jewish Senior Life Community, 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 five story, Type II (000), unprotected, noncombustible building, that 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 exceeded the maximum allowable story height for this type of construction, affecting six of six floors.

Findings include:

1. Observation on February 27, 2024, between 9:30 am and 10:00 am, revealed the facility exceeded the maximum allowable story height for an unprotected, noncombustible structure, by three stories.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 pm, confirmed the facility exceeded the maximum allowable story height for this type of construction.

Plan of Correction - To be completed: 04/05/2024

Elan Skilled Nursing and Rehab (facility) submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.

K0161 Building Construction

This is acceptable under the revised FSES dated 2/27/24.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0223

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

Findings include:

1. Observation on Feburary 27, 2024 at 11:18 a.m., basement level, revealed the Can Room door was being held open with trash cans.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the door was propped open.

Plan of Correction - To be completed: 04/05/2024

K0223 NFPA 101 Doors with Self-Closing Devices
1. The trash can was immediately removed by the Assistant Administrator once identified by the surveyor on 2/27/24.
2. An audit of the facility will be done by the Maintenance Director or designee to determine if other doors were being propped open that need to be closed.
3. The Department Managers will be educated by the Administrator on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

NFPA 101 STANDARD Exit Signage:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signs in one of seventeen smoke compartments.

Findings include:

1. Observation on Febraury 27, 2024, at 11:20 a.m., revealed the left side, from in the room, exit sign in the 1st floor chapel was not illuminated.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the exit sign was not lit.

Plan of Correction - To be completed: 04/05/2024

K293 NFPA 101-Exit Signage
1. The light bulb was replaced in the chapel exit sign by the Maintenance Director. The chapel was added to the TELS system audit for exit sign lights.
2. An audit of all exit signs to the building was completed by a Maintenance Assistance and all were properly lit.
3. The maintenance staff and Department Managers will be educated on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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, documentation review, and interview, it was determined the facility failed to maintain multiple vertical enclosures, affecting six of six floors.

Findings include:

1. Observation on February 27, at 10:15 a.m., revealed the following:

a. Vertical enclosures protecting heating, cooling, and ventilation (HVAC) shafts, adjacent to the exit stair towers, lacked the required two-hour fire resistance rating.

b. The fourth and fifth floor construction of the Clay Street exit stair tower consisted of two sheets of drywall on the inside and one sheet of drywall on the corridor and resident room side of metal studs, as well as unprotected steel beams included as part of the enclosure.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the vertical enclosures were not protected with the required hourly fire resistance rating.

Plan of Correction - To be completed: 04/05/2024

K0311 NFPA 101 Vertical Openings-Enclosures

This is acceptable under the revised FSES dated 2/27/24.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 doors to hazardous areas in one of seventeen smoke compartments.

Findings include:

1. Observation on February 27, 2024, at 10:25 a.m., revealed the 4th floor Soiled linen room door, near elevator #1, failed to latch in the frame when tested.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the door lacked positive latching.

Plan of Correction - To be completed: 04/05/2024

K0321 NFPA 101 Hazardous Areas - Enclosure
1. The latch to the soiled linen room on the 4th floor was repaired by the Maintenance Director.
2. An audit for the proper functioning of the door latches of the soiled unitality rooms on the 2nd, 3rd and 5th floors will be conducted by the Maintenance Director or designee. Any latch found to not be properly functioning will be repaired.
3. The Maintenance Director and maintenance staff will be educated by the Administrator or designee on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 six floors.

Findings include:

1. Observation on February 27, 2024, at 11:15 a.m., revealed several sprinklers in the main kitchen were loaded with lint or some other foreign substance.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the sprinklers were dirty.

Plan of Correction - To be completed: 04/05/2024

K0353 NFPA 101 Sprinkler System � Maintenance and Testing
1. The sprinkler heads cited were cleaned by the Maintenance Director.
2. An audit of the sprinkler heads will be completed by the Maintenance Director or designee in all the kitchens and dietary storage rooms. Any sprinkler heads found to have lint or other foreign substances on them will be cleaned.
3. The Maintenance Director will be educated by the Administrator or designee on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 smoke barriers on one of six floors, affecting two of seventeen smoke compartments.

Findings include:

1. Observation on Febraury 27, 2024, at 10:20 a.m., revealed the 4th floor smoke barrier near room 408 was sealed at the deck with a high expansion foam product.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the smoke barrier was not sealed using an authorized U.L. design system.

Plan of Correction - To be completed: 04/05/2024

K0372 NFPA 101 Subdivision of Building Spaces � Smoke Barrier
1. The 4th floor smoke barrier near room 408 was sealed at the deck by the Maintenance Director with an authorized U.L. design system product of 3M Fire Barrier Sealant (CP 25WB+).
2. An audit of one random smoke barrier area per floor will be conducted by the Maintenance Director or designee to check for any unauthorized fire sealant.
3. The Maintenance Director will be educated by the Administrator or designee on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

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 Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain two emergency generators which affects six of six floors.

Findings include:

1. Review of documentation on February 27,2024, between 9:30 a.m. and 10:30 a.m., revealed the facility could not provide documentation, that an annual fuel quality test was completed for both generators, within the last twelve months.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the fuel sample tests were not performed.

Plan of Correction - To be completed: 04/05/2024

K0918 NFPA 101 Electrical Systems � Essential Electric Systems
1. Upon further investigation it was discovered that the annual fuel quality tests were completed for both generators on 8/3/23.
2. No audit is to be completed since there are no other generators.
3. The company that has the Planned Maintenance Agreement with the facility was instructed to send the reports to the facility upon completion.
4. The results of the tests will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

NFPA 101 STANDARD Electrical Equipment - Other:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain the electrical system in one location, affecting one of six floors.

Findings include:

1. Observation on Feburary 27, 2024, at 11:19 a.m., revealed an unsecured electrical panel in the corridor, near the basement level can room.

Interview at the time of the exit conference with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the electrical panel was unsecured.

Plan of Correction - To be completed: 04/05/2024

K0919 NFPA 101 Electrical Equipment � Other
1. The electric panel cited was secured with a new lock by the Maintenance Director.
2. An audit of the electrical panels in the basement will be completed by the Maintenance Director of designee for compliance and repairs will be made if any are found to not meet this regulation.
3. The Maintenance Director will be educated by the Administrator or designee on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 the use of power taps on one of six floors.

Findings include:

1. Observation on Febraury 27, 2024, at 10:05 a.m., revealed several small appliances being powered by a surge protector at the 5th floor nurse station.

Interview with the Assistant Administrator and a Regional Representative on February 27, 2024, at 12:00 p.m., confirmed the appliances were being powered by a surge protector.

Plan of Correction - To be completed: 04/05/2024

K0920 NFPA 101 Electrical Equipment � Power Cords and Extension Cords
1. The surge protector was removed by the Assistant Administrator immediately when identified by the surveyor on 2/27/24.
2. All Nurses Station areas were audited by the maintenance department to determine if surge protectors were being used similarly. None were found.
3. The Nurse Unit Managers and Department Managers will be educated by the Nursing Home Administrator or designee on the regulation.
4. The results will be reviewed in the Monthly Quality Assurance and Process Improvement committee meeting.

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