Pennsylvania Department of Health
POTTSTOWN SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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POTTSTOWN SKILLED 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 July 9, 2024, at Pottstown Skilled Nursing and Rehabilitation 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 - Component: 01 - Tag: 0000

Facility ID# 380402
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on July 9, 2024, it was determined that Pottstown Skilled Nursing And Rehabilitation 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 five-story, Type II (000), unprotected noncombustible building, with a basement and a mechanical penthouse, 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 - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to update facility policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

Document review on July 9, 2024, at 8:45 a.m., revealed the facility failed to create a carbon monoxide alarm and evacuation plan.

Exit interview with the Administrator and the Director of Maintenance on July 9, 2024, at 12:00 p.m., confirmed the facility did not adhere to the Care Facility Carbon Monoxide Alarms Standards Act.

Plan of Correction - To be completed: 09/05/2024

Carbon Monoxide monthly testing and evacuation plan were located and will be emailed to the Life Safety Inspector. The policy and testing will be kept in the Life Safety binder in the Maintenance Department.

NFPA 101 STANDARD Building Construction Type and Height:

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 document review and interview, it was determined the facility failed to maintain building construction requirements, throughout five of five floors within the component.

Findings include:

Document review on July 9, 2024, at 8:45 a.m., revealed the building is a five-story, Type II (000), unprotected noncombustible building, that is fully sprinklered. A fully sprinklered building of this type may not exceed two stories.

Exit interview with the Administrator and the Director of Maintenance on July 9, 2024, at 12:00 p.m., confirmed the building exceeds allowable story height, by three floors.

Plan of Correction - To be completed: 09/07/2024

A Fire Safety evaluation survey was conducted on 1/14/2022 by Atlantic Code Consultants. On the 5th floor it was discovered that there were unprotected steel beams. Penetrations throughout the building were sealed in house by the Maintenance staff. The unprotected beams were sprayed by Acoustical Spray Insulators Inc. Plans will be submitted to the Plan Review Department for approval. The facility is choosing to eliminate the FSES pending approval of the plans. An investigation was performed by JKRP Architects for the purpose of having the building reclassified. Supporting evidence was submitted to the plan review department with a preliminary date/ time of 8/21/23 at 1:49:55 PM. An occupancy inspection will be requested following the approval of plan review.

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 paths of egress were continuously maintained free of all obstructions for full use in case of an emergency, affecting one of six levels in the facility.

Findings include:

Observation on July 9, 2024, at 11:40 a.m., revealed the exit door of basement boiler room required excessive force to open.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the excessive forced needed to open the door.

Plan of Correction - To be completed: 07/24/2024

1) Maintenance department adjusted push door assembly, tested the door several times and door now opens within 15 seconds as required.
2) Maintenance department will check weekly/monthly the Tels notification.
3) Departments will complete their monthly safety audits. Maintenance and Administration will review the audits to see if there are any doors that are not opening correctly.
4) Administration will review any findings at the monthly employee meetings.
5) Findings and recommendations will be discussed at the monthly QAPI meetings.

NFPA 101 STANDARD Egress Doors:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain delayed-egress doors, affecting one of six levels in the facility.

Findings include:

Observation on July 9, 2024, at 11:42 a.m., revealed the basement delayed egress door by the kitchen failed to open.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the door failed to open.

Plan of Correction - To be completed: 08/09/2024

1) Maintenance department adjusted push door assembly, tested the door several times and door now opens within 15 seconds as required.
2) Maintenance department will check weekly/monthly the Tels notification.
3) Departments will complete their monthly safety audits. Maintenance and Administration will review the audits to see if there are any doors that are not opening correctly.
4) Administration will review any findings at the monthly employee meetings.
5) Findings and recommendations will be discussed at the monthly QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 document review, observation, and interview, it was determined the facility failed to provide quarterly sprinkler inspection reports, affecting the entire facility.

Findings include:

1. Document review on July 9, 2024, between 8:45 a.m. and 11:38 a.m., revealed the facility failed to provide documentation of the following tests and inspections for the sprinkler system:

a. Third quarter inspection for 2023;
b. Electric pump monthly 10 minute run.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the lack of documentation.

2. Observations on July 9, 2024, between 11:04 a.m. and 11:38 a.m., revealed the following sprinkler system deficiencies:

a. 11:04 a.m., Soiled Linen next to resident room 201, missing ceiling tile, which could delay activation of the sprinkler system;
b. 11:38 a.m., excessive debris on sprinklers in the Kitchen

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 08/09/2024

1) 3Q Inspection report has been located and placed in the Life Safety Binder. 2) Electric pump inspection report located and placed in the Life Safety binder and both documents will be sent to the Life Safety Supervisor.
3) Maintenance Staff cleaned both the walk-in cooler sprinkler heads on Monday, July 29th.
4) Maintenance Staff will review Dietary's monthly Safety Audits for any additional debris on any of the sprinkler heads.

NFPA 101 STANDARD Sprinkler System - Out of Service:

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0354

Based on document review and interview, it was determined the facility failed to provide a fire watch policy, affecting the entire facility.

Findings include:

Document review on July 9, 2024, between 8:45 a.m. and 11:38 a.m., revealed the facility failed to provide documentation of a fire watch.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 08/31/2024

Fire watch documentation was located and will be sent to the Life Safety Inspector. Center will Secure the Fire Watch Report after the event occurs and place it in the Life Safety binder along with the policy.
All maintenance staff will be in-serviced on the policy and procedure.

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 barrier walls free of unsealed penetrations, affecting one of six levels in the facility.

Findings include:

Observation on July 9, 2024, at 11:06 a.m., revealed on the second floor, above the ceiling of the smoke barrier doors next to resident room 201, multiple open penetrations.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the multiple penetrations.

Plan of Correction - To be completed: 08/09/2024

1) Existing fire caulk was removed and proper rated fire caulk was applied above the ceiling of the smoke barrier doors next to room 201 by Maintenance Staff on 7/24/2024.

NFPA 101 STANDARD Utilities - Gas and Electric:

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 - 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 two of six levels in the facility.

Findings include:

1. Observation on July 9, 2024, between 11:12 a.m. and 11:47 a.m., revealed the following deficiencies:

a. 11:12 a.m., on the second floor dialysis storage, there was a blocked electrical panel;
b 11:47 a.m., in the basement elevator machine room, the elevator controls lacked a front cover.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the blocked electrical panel and missing cover.

2. Observation on July 9, 2024, between 11:12 a.m. and 11:15 a.m., revealed a non-GFCI outlet located within 6 feet of a sink in the following locations:

a. 11:12 a.m., on the second floor, dialysis room;.
b. 11:15 a.m., on the second floor, med room by resident room 217.

(Refer to NFPA 70, National Electric Code, Section 210.8(B)5)

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the non-GFCI outlets installed within 6 feet of sinks

Plan of Correction - To be completed: 09/01/2024

1a: Department heads were educated during July 23rd QAPI and monthly Safety meeting that were held the same day. Department heads will educate their staff on a continual basis. 1b):Zeller electric was called on 7/26/2024 come up with a plan to cover the panel with a proper electrical box. Zeller will put a lock on the outer cage. The Key will be labeled and kept in the maintenance department. Staff will be inserviced on where to locate the key in the event of an emergency. 2a) The outlets identified in dialysis are tied into a GFCI breaker panel. Supporting photos will be sent to the Life Safety Inspector. 2b) Zeller to install GFCI outlet in 2nd floor med room.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to provide fire drill documentation, affecting one of twelve drills.

Findings include:

Document review on July 9, 2024, between 8:45 a.m. and 11:38 a.m., revealed the facility failed to provide documentation verifying the fourth quarter fire drill.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 08/15/2024

Fire drills are conducted on a monthly basis. Fire drill logs are located and placed in the Life Safety binder. Supporting documentation will be sent to the Life Safety Inspector.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on document review and interview, it was determined the facility failed to provide documentation of the facility's smoking policy, affecting the entire facility.

Findings include:

Document review on July 9, 2024, between 8:45 a.m. and 11:38 a.m., revealed the facility failed to provide documentation of a policy for smoking / non-smoking.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 08/09/2024

1)The smoking policy was located and supporting documentation will be sent to the Life Safety Supervisor.
2) Center's smoking policy will be kept in each Emergency Preparedness Program (EPP) manual(s) on the units.
3) Department heads will monitor adherence to the policy within and outside the center when completing their monthly safety audits.
4) Maintenance and Administration will review the audits to see if there are non compliant residents, staff and visitors.
5) Administration will review any findings at the monthly employee meetings.
6) Findings and recommendations will be discussed at the monthly QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document Review on July 9, 2024, between 8:45 a.m. and 11:38 a.m., revealed the facility failed to provide documentation of the following tests and inspections:

a. Monthly 30 minute load test;
b. Generator preventative maintenance indicating there was no evidence of wet stacking;
c. Annual fuel quality test.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 09/01/2024

1a: Monthly 30 Minute load document was located and will be sent to the Life Safety Inspector. 1b: Documentation located and will be sent to the Life Safety Inspector. 1c: Annual Fuel Quality test was completed on 1/11/2024 but the center did not receive the report. The center contacted Henry's Generator on 7/16/2024 to send us the full report. Once received, center will send documentation to the Life Safety Supervisor.

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 prevent the improper use of power strips and outlet multipliers, affecting one of six levels of the facility.

Findings include:

Observation on July 9, 2024, at 10:51 a.m., revealed on the third floor in the RN office, there was a coffee maker plugged into a power strip.

Exit interview with the Administrator and Maintenance Director on July 9, 2024, at 12:00 p.m., confirmed the improper use of power strips.

Plan of Correction - To be completed: 09/01/2024

1) Power strip was removed.
2) Reviewed this during our 7/24/2024 Safety meeting and Staff meetings on 7/23 and 7/25.
3) Department heads will monitor adherence to the policy within the center when completing their monthly safety audits.
4) Maintenance and Administration will review the audits to see if there are non compliant residents, staff and visitors.
5) Administration will review any findings at the monthly employee meetings.
6) Findings and recommendations will be discussed at the monthly QAPI meetings.

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