Nursing Investigation Results -

Pennsylvania Department of Health
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE
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.
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE - 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 March 23, 2022, at St. Mary Center For Rehabilitation & Healthcare, 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# 451402
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on March 23, 2022, it was determined St. Mary Center For Rehabilitation & Healthcare 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 one-story, Type V (111), protected wood frame structure, with an attic, which is fully sprinklered.




 Plan of Correction:


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 meet the requirements for egress, in one of over four wings.

Findings include:

Observation on March 23, 2022, at 11:22 a.m., revealed the facility had benches unsecured, resident hallway, obstructing the full use of the egress near resident dining.

Exit Interview with the Administrator and Maintenance Supervisor on March 23, 2022, at 11:22 a.m., confirmed the egress obstruction.





 Plan of Correction - To be completed: 05/15/2022

1. The Unsecured benches in the hallway have been removed.
2. Maintenance staff will be in-serviced that when doing rounds, to ensure that all means of egress is continuously maintained free of all obstructions to full use in case of an emergency.
3. Audits will be conducted monthly X1 by maintenance director/ designee. Findings of the audits will be submitted to QAPI for review and recommendations.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to meet the requirements for sprinkler systems, in two of more than four wings.

Findings include:

Observation on March 23, 2022, between 9:42 a.m. and 11:46 a.m., revealed the following sprinkler head escutcheons were missing allowing the passage of smoke and possible delay of the sprinkler system:

A. 9:42 a.m., Environmental Services Office;
B. 11:46 a.m., Outside the conference room.

Exit Interview with the Administrator and Maintenance Supervisor on March 23, 2022, at 11:46 a.m., confirmed the sprinkler system deficiencies listed above.





 Plan of Correction - To be completed: 05/15/2022

1. Sprinkler escutcheons were missing inside environmental office and outside conference room and will be added to provide a complete sprinkler head design.
2. Maintenance staff will be in-serviced that when doing rounds, to be aware of any missing escutcheons.
3. A facility wide inspection of escutcheons will be conducted.
4. Audits will be conducted monthly X1 by maintenance director/ designee. Findings of the audits will be submitted to QAPI for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 observation and interview, it was determined the facility failed to meet requirements for essential electrical systems.

Findings include:

Observation on March 23, 2022, at 9:02 a.m., revealed the facility failed to provide documentation the annual fuel quality sample had been completed at the time of the survey.

Exit Interview with the Maintenance Supervisor on March 23, 2022, at 9:02 a.m., confirmed the annual fuel quality sample documentation was not provided at the time of the survey.





 Plan of Correction - To be completed: 05/15/2022

1. The generator fuel samples will be taken and facility will maintain annual fuel samples
2. Maintenance staff will be educated on maintaining the Generator fuel sample log
3. Audits will be conducted monthly X1 by maintenance director/ designee. Findings of the audits will be submitted to QAPI for review and recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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 meet the requirements for electrical equipment, in three of over fifty rooms.

Findings include:

Observation on March 23, 2022, between 10:00 a.m. and 11:02 a.m., revealed the following electrical equipment deficiencies:

A. 10:00 a.m., Education office, had a refrigerator plugged into a surge protector;
B. 10:21 a.m., Francis wing, oxygen room, had a six to one outlet multiplier;
C. 11:02 a.m., Therapy, had a refrigerator and coffee pot plugged into a surge protector in a patient care area.

Exit Interview with the Administrator and Maintenance Supervisor on March 23, 2022, at 11:02 a.m., confirmed the electrical equipment deficiencies listed above.





 Plan of Correction - To be completed: 05/15/2022

1. The facility has corrected all electrical equipment issues. The six to one outlet multiplier will be removed and replaced with additional outlets.

2. Maintenance staff will be educated on inspecting and maintaining the facility wide electrical equipment
3. A facility wide inspection of electrical equipment has been conducted and all working as designed.
4. Audits will be conducted monthly X1 by maintenance director/ designee. Findings of the audits will be submitted to QAPI for review and recommendations.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port