Pennsylvania Department of Health
 TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE
Inspection Results For:

There are  37 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.
TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE - 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 May 29, 2024, at The Transitional Care Unit At Nazareth Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0000


Facility ID# 400302
Component 01
St. Joseph's Building

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2024, it was determined that The Transitional Care Unit At Nazareth Hospital - St Joseph's Building 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 seven-story, Type II (222), fire resistive building, with a ground floor, basement, and a penthouse, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain required inspections of emergency lighting, affecting two of seven floors.

Findings include:

Document review on May 29, 2024, at 9:00 a.m., revealed the facility lacked documentation for annual 90-minute testing of battery back-up lighting:

Exit Interview with the Facility Operations Manager on May 29, 2024, at 11:45 a.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 07/26/2024

Manager of Plant Operations was able to locate the documentation for the Annual 90-minute testing of battery back up lighting which occurred in Aug of 2023.

The next annual testing is due August 0f 2024.

Monitoring of this annual paper work will be added to the preventative maintenance check list.

Manager of Plant Operations will monitor

Review of this deficiency will be added to the quality improvement meeting.


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: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, Section 210.8(B) 5 for electrical wiring and equipment, affecting one of seven floors.

Findings include:

Observation on May 29, 2024, at 11:00 a.m., revealed on the sixth floor, in the Staff Lounge, a non-GFCI outlet located within 6 feet of a sink.

Exit Interview with the Facility Operations Manager on May 29, 2024, at 11:45 a.m., confirmed the outlet.





 Plan of Correction - To be completed: 07/26/2024

A GFCI outlet was installed on the day of survey May 29th 2024.

An inspection of outlets will occur during the Plant Operations environment of care rounds

Manager of Plant Operations will round and monitor

This deficiency will be reviewed during the Quality Improvement meeting
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting three of seven floors.

Findings include:

Document review on May 29, 2024, at 9:00 a.m., revealed the July 2023, Annual Fire Door Inspection report listed 12- fire doors as deficient, evidence of corrective action was not available at time of survey.

Exit Interview with the Facility Operations Manager on May 29, 2024, at 11:45 a.m., confirmed the rated door deficiencies.




 Plan of Correction - To be completed: 07/26/2024

* Vendor is scheduled to come to Nazareth Hospital on 6/17/23.

*A plan will be developed for continued monitoring of the doors

*The doors will be serviced, replaced and/or ordered

* The monitoring of the doors will be added to the environment of care rounds.

*Completion and monitoring will occur by manager of plant operations

*This deficiency will be reviewed at the quality improvement committee

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance Pr: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.
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0907

Based on documentation review and interview, it was determined the facility failed to maintain the medical gas system, affecting one of seven floors.

Findings include:

Document review on May 29, 2024, at 9:00 am, revealed the following deficiencies listed on the February 2024, Medical Gas Report. Corrective action was not available at time of survey.

a. Replace damaged vacuum faceplate room 618.
b. Replace damaged oxygen faceplate in washer room.

Exit Interview with the Facility Operations Manager on May 29, 2024, at 11:45 a.m., confirmed the medical gas deficiencies.




 Plan of Correction - To be completed: 07/26/2024

This was corrected by vendor on 5/30/24. they replaced damaged vacuum faceplate in room 618 and replaced damaged oxygen faceplate in washer room.

Vendor advised to make real time corrections when needed, vendor advised they were waiting for parts.

Manager of Plant operations add to environment of care rounds

This deficiency will be reviewed at the quality improvement meeting


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