Pennsylvania Department of Health
NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 surveys for this facility. Please select a date to view the survey results.

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NORTHERN DAUPHIN 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 24, 2024, at Northern Dauphin 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 #451902
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on July 24 & 25, 2024, it was determined that Northern Dauphin Nursing and Rehabilitation Center 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 two-story, Type II (000), unprotected noncombustible structure, which 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

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on July 24, 2024, between 9:15 AM and 11:15 AM, revealed the facility floor plans lacked resident room capacities, fire wall boundaries, smoke wall boundaries and hazardous areas, which is required by CMS for the FSES.

Interview with the Administrator and Maintenance Director on July 24, 2024, at 1:45 PM,
confirmed the floor plans lacked required information for an FSES.

Plan of Correction - To be completed: 08/26/2024

1. Facility updated facility floor plan to reflect facility portable life safety with resident's room capacities, hazardous areas, travel distance from the furthest point in the one to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, length and width of zone and labeled use of space. The Maintenance director or designer will update the floor plan as needed when any changes occur.

2. The Maintenance Director will audit annually floor plans and report findings to the QAPI committee for further action planning.

3. Date of Compliance August 26, 2024

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 maintain special locking arrangements lacked delayed egress signage, in two of four smoke zones within the component.

Findings include:

1. Observation on July 24, 2024, between 12:45 PM and 12:53 PM, revealed the exit discharge doors lacked delayed egress signage, at the following locations:

a. 12:45 PM, 1st floor, 100 Stairtower door;
b. 12:48 PM, 1st floor, 200 Stairtower door;
c. 12:49 PM, 1st floor, 300 Stairtower door;
d. 12:50 PM, 1st floor, 400 Stairtower door;
e. 12:53 PM, 1st floor, Ambulance access door.

Interview with the Administrator and Maintenance Director on July 24, 2024, at 1:45 PM, confirmed exit doors lacked signage.

Plan of Correction - To be completed: 08/26/2024

1. Delayed egress signage was applied to all doors during survey process.

2. Maintenance Director/Designee will conduct random audits monthly for 3 months and quarterly thereafter to ensure the signage that has been applied remains intact. Reports to be submitted to QAPI monthly.

3. Date of Compliance August 26, 2024

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the monitoring devices to be mounted, according to manufacturer's specifications, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on July 25, 2024, at 11:35 AM, revealed the heat detector assembly detached and hanging above ceiling, on the 2nd floor, by Resident Room 814.

Interview with the Regional Director and Maintenance Director on July 25, 2024, at 1:30 PM, confirmed the heat detector was detached and hanging above ceiling.

Plan of Correction - To be completed: 08/26/2024

1. Heat detector assembly has been remounted by Johnson Control on August 6, 2024.

2. Maintenance Director will be educated on Fire Alarm Testing and Inspections regulations per NFPA 72.

3. Maintenance Director/Designee will conduct monthly audits to ensure Fire Alarm Devices are mounted per manufacturer instructions. Results to QAPI.

3. Date of Compliance August 26, 2024

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

Plan of Correction - To be completed: 08/26/2024

1. All sprinkler heads were cleaned in the areas indicated during survey and all sprinkler heads will now be included in the routine cleaning schedule to be completed by Maintenance; All wires, flex duct, rigid duct and conduits that were observed laying across sprinkler pipes has since been corrected.

2. Maintenance Director/Designee will conduct random audits of sprinkler heads monthly for 3 months to ensure they are clean and free of debris and then quarterly thereafter. Results to QAPI.

3. Date of Compliance August 26, 2024

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed provide a certificate for the Fire Extinguisher Technician, affecting four of four smoke compartments within the component.

Findings include:

1. Review of documentation on July 24, 2024, between 9:15 AM and 11:15 AM, revealed the facility lacked documentation of the annual inspection being completed by a Certified Fire Extinguisher Inspector.

Interview with the Administrator and Maintenance Director on July 24, 2024, at 1:45 PM,
confirmed the facility could not provide a certification for Fire Extinguisher Inspector.

Plan of Correction - To be completed: 08/26/2024

1. Peifer's Fire Protection provides our annual inspection services. Due to the lack of documentation from our first 2024 inspection, they completed a 2nd inspection on August 7, 2024. Documentation is now on file for the 2nd inspection that has been completed for the year 2024.

2. Maintenance/Designee will retain future inspection tags/documentation and have readily available to surveyors.

3. NHA/Designee will audit documentation and results to be reported to QAPI.

3. Date of Compliance August 26, 2024.

NFPA 101 STANDARD Corridor - Doors:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to self-close, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on July 25, 2024, at 11:15 AM, revealed the upper level Chapel double smoke barrier door, left leaf (with latching hardware), did not close and latch, due to a malfunctioning coordinator.

Interview with the Regional Director and Maintenance Director on July 25, 2024, at 1:30 PM, confirmed the doors did not close and latch in frame.

Plan of Correction - To be completed: 08/26/2024

1. The Chapel barrier door malfunctioning leaf latching hardware has been repaired to allow for door to latch properly.

2. Maintenance/Designee will audit doors weekly to ensure doors properly close and latch without obstruction. Results to be reviewed at QAPI.

2. Date of Compliance August 26, 2024

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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.

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to maintain smoke compartment size and travel distance, for two of four smoke compartments within the component.

Findings include:

1. Observation on July 24, 2024, between 11:00 AM and 1:30 PM, revealed smoke compartments 2 and 4 exceeded 22,500 square feet, with travel distances exceeding 200 feet.

Interview with the Administrator and Maintenance Director on July 24, 2024, at 1:45 PM, confirmed the smoke compartments exceeded the maximum limits for size and travel distance.

Plan of Correction - To be completed: 08/26/2024

1. The facility requests DSI to conduct FSES.

2. Date of Compliance August 26, 2024.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility lacked documentation, verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component.

Findings include:

1. Review of documentation on July 24, 2024, between 9:15 AM and 11:15 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance.

Interview with the Administrator and Maintenance Director on July 24, 2024, at 1:45 PM,
confirmed the facility lacked documentation for fire dampers.

Plan of Correction - To be completed: 08/26/2024

1.Johnson Control inspected facility for fire dampers and have determined there is one in the facility in the 200 hall area.

2. The Fire damper has been inspected/tested in accordance with NFPA 101, results are expected on file by compliance date.

3. Fire Damper inspection/testing has been added to the facility electronic Preventative Maintenance Program. Audit to be completed annually to confirm inspection results on file, any repairs have been completed and next inspection has been scheduled. Results to QAPI.

4. Date of Compliance August 26, 2024

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 to provide annual fuel quality analysis for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on July 24, 2024, between 9:15 AM and 11:15 AM, revealed the facility lacked documentation for the annual fuel quality test.

Interview with the Administrator and Maintenance Director on July 24, 2024, at 1:45 PM,
confirmed the facility lacked documentation for annual fuel quality test.

Plan of Correction - To be completed: 08/26/2024

1. Facility has documentation that Penn Power Systems completed the annual Fuel Sample Test but they are unable to provide the results of 2023 test; Facility has documentation which shows 2024 Fuel Sample Test has been completed however those results have not yet been received. Results are expected by our date of compliance listed below.

2. Maintenance/Designee will ensure all results of tests performed are received and documentation be available for reference if needed and complete audits monthly for 3 months and then quarterly to ensure all documentation has been received. Results to be reviewed at QAPI.

3. Date of Compliance August 26, 2024.

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