Nursing Investigation Results -

Pennsylvania Department of Health
LEBANON VALLEY BRETHREN HOME
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LEBANON VALLEY BRETHREN HOME
Inspection Results For:

There are  36 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.
LEBANON VALLEY BRETHREN HOME - 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 September 11, 2019, at Lebanon Valley Brethren Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: LEFFLER - Component: 02 - Tag: 0000


Facility ID# 380602
Component 02
Leffler Building

Based on a Medicare/Medicaid Recertification Survey completed on September 11, 2019, it was determined that Lebanon Valley Brethren Home 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: LEFFLER - Component: 02 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the rating of common walls, and common walls doors to positively latch, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on September 11, 2019, at 1:15 PM revealed a penetration around data wires had been sealed with orange foam, above the common wall doors separating the Nursing Care from Personal Care.

Interview with the Director of Environmental Services on September 11, 2019, at 1:15 PM confirmed an unapproved substance was in the common wall.


2. Observation on September 11, 2019, at 1:15 PM revealed the common wall doors separating the Nursing Care from Personal Care failed to positively latch.

Interview with the Director of Environmental Services on September 11, 2019, at 1:15 PM confirmed the common wall doors failed to positively latch.


 Plan of Correction - To be completed: 10/28/2019

The 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 and to challenge the accuracy of the alleged deficiencies or an admission of past or ongoing violations of State or Federal regulatory requirements.

0133

The penetration around the data wires has been sealed with an approved stop gap penetration system. Thank you sealant
The rated doors separating PC from Nursing care have been adjusted by maintenance to positively latch.
Maintenance department will do weekly door inspections to ensure proper closing. Maintenance director will monitor results and take to QAPI for further recommendations.
Effective 10/28/2019

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: LEFFLER - Component: 02 - Tag: 0347
Based on observation and interview, it was determined the facility failed to maintain smoke detectors to be free of obstruction, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on September 11, 2019, at 12:50 PM revealed the smoke detector in the IT/Cable Room had a cover installed.

Interview with the Director of Maintenance on September 11, 2019, at 12:50 PM confirmed the detector was covered.


 Plan of Correction - To be completed: 10/28/2019

0347
The cover was removed from the smoke detector in the IT room.
The maintenance staff will be educated on the regulation and how it relates to the deficiency.
Maintenance director/designee to monitor rooms under construction or repair weekly for compliance.
The results will be taken to the QAPI committee for compliance
Effective 10/28/2019

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: LEFFLER - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, in three of six smoke compartments within the component.

Findings include:

1. Observation on September 11, 2019, between 12:15 PM and 12:55 PM revealed corridor doors were hitting either the neighboring leaf, or the frame, which prevented them from closing and positively latching, at the following locations:

a. 12:15 PM, Resident Room 325/327, the double doors were hitting each other;
b. 12:17 PM, Resident Room 324/326, the double doors were hitting each other;
c. 12:20 PM, Resident Room 322 was impeded by the privacy curtain;
d. 12:25 PM, Resident Room 320 was impeded by a waste basket;
e. 12:35 PM, Spa, by Personal Laundry was impeded by a walker;
f. 12:45 PM, Resident Room 305/307, the double doors were hitting each other;
g. 12:55 PM, Shower Room, by Resident Room 309, was hitting the frame;

Interview with the Director of Maintenance on September 11, 2019, at 12:55 PM confirmed the corridor door deficiencies.


2. Observation on September 11, 2019, at 1:05 PM, revealed the doors to the Serving Kitchen did not close and positively latch.

Interview with the Director of Maintenance on September 11, 2019, at 1:05 PM confirmed the door failed to positively latch.





 Plan of Correction - To be completed: 10/28/2019

0363

1a) Resident room 325/327 had the doors adjusted by maintenance to close properly.
1b) Resident room 324/326 had the doors adjusted by maintenance to close properly
1c) Resident room 322 had the privacy curtain returned to normal position away from the doors
1d) Resident room 320 had the trash can removed from the doorway.
1e) Spa room had the walker removed from the doorway
1f) Resident room 305/307 had the doors adjusted by maintenance to close properly.
1g) Shower room/BR door by room 309 was adjusted to close properly
2) Serving Kitchen doors were adjusted by maintenance to close properly.
Maintenance will do door checks weekly.
Maintenance Director will monitor results and take the results of the door checks to the QAPI committee for further recommendations.
Effective 10/28/19

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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: LEFFLER - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier door hardware to function, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on September 11, 2019, at 1:30 PM revealed the double smoke barrier doors, by Resident Room 407, were equipped with latching hardware, which during the survey, did not close and latch.

Interview with the Director of Maintenance on September 11, 2019, at 1:30 PM
confirmed the doors did not latch.




 Plan of Correction - To be completed: 10/28/2019

0374
Double smoke barrier doors by room 407 on TT will be adjusted by maintenance to positively latch.
Maintenance Department will do weekly door inspections.
Maintenance Director will monitor result and take to QAPI committee for further recommendations.
Effective 10/28/2019

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: LEFFLER - Component: 02 - Tag: 0754

Based on observation and interview, it was determined the facility failed to properly store receptacles, with a combined or single capacity exceeding 32 gallons, when left unattended, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on September 11, 2019, at 12:30 PM revealed a shredder and trash containers, exceeding 32 gallons, were being stored in an Office off the Nurses' Station, by Resident Room 320, and were stored outside of a protected hazardous storage area.

Interview with the Director of Maintenance on September 11, 2019, at 12:30 PM confirmed the shredder and trash containers were stored outside of a protected hazardous storage area.

2. Observation on September 11, 2019, at 1:20 PM revealed a shredder and 3 trash containers, exceeding 32 gallons, were being stored in the Nurses' Station, by the Lounge, and were stored outside of a protected hazardous storage area.

Interview with the Director of Maintenance on September 11, 2019, at 1:20 PM confirmed the shredder and trash containers were stored outside of a protected hazardous storage area.





 Plan of Correction - To be completed: 10/28/2019

0754
1)The shredder box in Leffler copy room will be adjusted to have a smaller capacity to meet the requirements of the regulation.
2)The shredder box will be adjusted to have a smaller capacity and the trash cans will be adjusted/moved so the area meets the requirements of the regulation.
Maintenance Director/ designee will monitor monthly for compliance and take the results to the QAPI committee for further recommendations
Effective 10/28/2019

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: LEFFLER - Component: 02 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observation on September 11, 2019, at 12:05 PM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on September 11, 2019, at 12:05 PM confirmed the switch had not been installed.




 Plan of Correction - To be completed: 10/28/2019

0918
A remote manual stop for the emergency generator will be installed to meet the regulation.
Maintenance Director & Environmental Services Director will be educated on the regulation and how it pertains to the cited deficiency so it does not reoccur.
Maintenance Director will notify generator company and ensure installation for compliance of the regulation.
Effective 10/24/2019

NFPA 101 STANDARD Electrical Equipment - 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 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: LEFFLER - Component: 02 - Tag: 0919

Based on observation and interview, it was determined the facility failed to protect electrical wiring, plugs and receptacles, in two of six smoke compartments within the component.

Findings include:

1. Observation on September 11, 2019, at 1:25 PM revealed the electrical receptacle and box, in Resident Room 410, had been dislodged from the wall.

Interview with the Director of Maintenance on September 11, 2019, at 1:25 PM confirmed the exposed box and receptacle.





 Plan of Correction - To be completed: 10/28/2019

0919
Maintenance repaired the receptacle box in room 410.
Maintenance will do monthly checks of room receptacles
Maintenance Director will monitor results and take to the QAPI committee for further recommendations
Effective 10/28/2019


Initial comments:Name: UNIT 1 - Component: 03 - Tag: 0000


Facility ID# 380602
Component 03
Hostetter House (12 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on September 11, 2019, it was determined that Lebanon Valley Brethren Home 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: UNIT 1 - Component: 03 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observation on September 11, 2019, at 1:45 PM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on September 11, 2019, at 1:45 PM confirmed the switch had not been installed.





 Plan of Correction - To be completed: 10/28/2019

0918
A remote manual stop for the emergency generator will be installed to meet the regulation.
Maintenance Director & Environmental Services Director will be educated on the regulation and how it pertains to the cited deficiency so it does not reoccur.
Maintenance Director will notify generator company and ensure installation for compliance of the regulation.
Effective 10/24/2019

Initial comments:Name: UNIT 2 - Component: 04 - Tag: 0000


Facility ID# 380602
Component 04
Castagna Cottage (11 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on September 11, 2019, it was determined that Lebanon Valley Brethren Home 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: UNIT 2 - Component: 04 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observation on September 11, 2019, at 1:45 PM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on September 11, 2019, at 1:45 PM confirmed the switch had not been installed.




 Plan of Correction - To be completed: 10/28/2019

0918
A remote manual stop for the emergency generator will be installed to meet the regulation.
Maintenance Director & Environmental Services Director will be educated on the regulation and how it pertains to the cited deficiency so it does not reoccur.
Maintenance Director will notify generator company and ensure installation for compliance of the regulation.
Effective 10/28/2019

Initial comments:Name: UNIT 3 - Component: 05 - Tag: 0000


Facility ID# 380602
Component 05
Fake Cottage (8 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on September 11, 2019, it was determined that Lebanon Valley Brethren Home 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: UNIT 3 - Component: 05 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observation on September 11, 2019, at 1:45 PM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on September 11, 2019, at 1:45 PM confirmed the switch had not been installed.




 Plan of Correction - To be completed: 10/28/2019

0918
A remote manual stop for the emergency generator will be installed to meet the regulation.
Maintenance Director & Environmental Services Director will be educated on the regulation and how it pertains to the cited deficiency so it does not reoccur.
Maintenance Director will notify generator company and ensure installation for compliance of the regulation.
Effective 10/24/2019

Initial comments:Name: UNIT 4 - Component: 06 - Tag: 0000


Facility ID# 380602
Component 06
Royer Cottage (7 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on September 11, 2019, it was determined that Lebanon Valley Brethren Home 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: UNIT 4 - Component: 06 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observation on September 11, 2019, at 1:45 PM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on September 11, 2019, at 1:45 PM confirmed the switch had not been installed.




 Plan of Correction - To be completed: 10/28/2019

0918
A remote manual stop for the emergency generator will be installed to meet the regulation.
Maintenance Director & Environmental Services Director will be educated on the regulation and how it pertains to the cited deficiency so it does not reoccur.
Maintenance Director will notify generator company and ensure installation for compliance of the regulation.
Effective 10/28/2019

Initial comments:Name: RECREATION ROOM 103 - Component: 07 - Tag: 0000


Facility ID #380602
Component 07
Recreation Room

Based on a Medicare/Medicaid Recertification Survey completed on September 11, 2019, it was determined that Lebanon Valley Brethren Home 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: RECREATION ROOM 103 - Component: 07 - Tag: 0918
Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observation on September 11, 2019, at 1:45 PM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6

Interview with the Director of Maintenance on September 11, 2019, at 1:45 PM confirmed the switch had not been installed.


 Plan of Correction - To be completed: 10/28/2019

0918
A remote manual stop for the emergency generator will be installed to meet the regulation.
Maintenance Director & Environmental Services Director will be educated on the regulation and how it pertains to the cited deficiency so it does not reoccur.
Maintenance Director will notify generator company and ensure installation for compliance of the regulation.
Effective 10/28/2019


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