Pennsylvania Department of Health
SCHUYLKILL CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 37 surveys for this facility. Please select a date to view the survey results.

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SCHUYLKILL 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 May 20, 2024, at Schuylkill 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 - Component: 01 - Tag: 0000

Facility ID #453002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2024, it was determined that Schuylkill 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 (222), fire resistive structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain the continuous illumination of exit signage, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on May 20, 2024, at 11:16 AM, revealed the exit sign, within the "B" Wing Kitchenette, by Resident Room 282, was not illuminated.

Interview with the Maintenance Director on May 20, 2024, at 11:16 AM, confirmed the exit sign was not illuminated.

Plan of Correction - To be completed: 06/19/2024

1. The bulb in the exit sign near room 282 was replaced during the survey.
2. Maintenance staff will audit the exit signs throughout the facility and report findings to the QAPI Committee. A facility wide master exit sign spreadsheet audit has been developed to verify that each sign is inspected for illumination monthly during the audit process.
3. Random audits of exit signs will occur monthly to verify ongoing compliance. Results of audits will be reported to QAPI committee monthly.

4. Date of correction is 6/19/2024

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting four of seven smoke compartments within the component.

Findings include:

1. Observation on May 20, 2024, between 11:22 AM and 12:25 PM, revealed unprotected penetrations on the doors to Soiled Utility Rooms, at the following locations:

a) 11:22 AM, next to Resident Room 267;
b) 11:35 AM, next to Resident Room 217;
c) 12:15 PM, next to Resident Room 117;
d) 12:25 PM, next to Resident Room 116.

Interview with the Maintenance Director on May 20, 2024, at 12:25 PM, confirmed the unprotected penetrations of the doors to hazardous area enclosures.

Plan of Correction - To be completed: 06/19/2024

1. The penetrations in the Soiled Utility Rooms next to resident rooms 267, 217, 117 and 116 will be repaired using an approved accessory or steel bolts.

2. Maintenance staff will receive education on how to repair penetrations to maintain protection requirements of the doors.
3. Maintenance staff will continue to audit the soiled utility rooms throughout the facility for penetrations monthly. Facility fire doors will continue to be inspected at least annually. Random audits of soiled utility doors and fire doors will occur quarterly within two weeks of annual inspection and on any doors that have hardware replaced. Findings will be reviewed at the monthly QAPI Committee.

Date of correction is 6/19/2024

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide documentation verifying quarterly inspections of the automatic sprinkler protection system, and to maintain the system in a continuously reliable operating condition, affecting the entire component.

Findings include:

1. Review of documentation on May 20, 2024, at 10:40 AM, revealed the facility failed to provide documentation verifying the automatic sprinkler protection system had been inspected since 10/12/2023.

Interview with the Maintenance Director on May 20, 2024, at 10:40 AM, confirmed the lack of documentation verifying the automatic sprinkler system had been inspected since 10/12/2023.

2. Observation on May 20, 2024, at 12:10 PM, revealed two sprinkler heads, protecting the area behind the dryers, within the Laundry, were suspended in the void created by the lack of ceiling tiles within the ceiling grid.

Interview with the Maintenance Director on May 20, 2024, at 12:10 PM, confirmed the lack of ceiling tiles within the suspended ceiling grid.

Plan of Correction - To be completed: 06/19/2024

1. The quarterly sprinkler inspections will be scheduled with a vendor that performs same. Reports will be filed in the Life Safety book by maintenance. NHA or designee will audit the Life Safety Book to confirm that sprinkler reports have been received and filed.

2. The void in the ceiling tiles will be repaired behind the dryers.
The maintenance director or designee will schedule quarterly sprinkler inspections quarterly and report findings to the QAPI Committee. Maintenance staff will audit ceiling tiles to identify and then repair any areas of concern. Findings will be reviewed at the monthly QAPI Committee meeting.

Date of correction is 6/19/2024

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

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 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain the installation of portable fire extinguishers, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on May 20, 2024, at 12:12 PM, revealed the portable fire extinguisher, located within the Kitchen Freezer Area, was placed on the floor beneath the extinguisher mounting bracket.

Interview with the Maintenance Director on May 20, 2024, at 12:12 PM, confirmed the portable fire extinguisher was not mounted on the wall.

Plan of Correction - To be completed: 06/19/2024

1. The fire extinguisher near the kitchen freezer area will be mounted in a mounting bracket.
2. Fire extinguishers in facility will be checked monthly for all items contained on the owner's quick check including: pressure, safety ties in place, nozzle in good condition, gauge facing front and mounting not less than 3 inches from the floor and not higher than 60 inches at the gauge.
3. Results of monthly quick checks will be reviewed at monthly QAPI meeting quarterly.
Date of correction is 6/19/2024.

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on May 20, 2024, between 11:20 AM and 12:01 PM, revealed unprotected penetrations of corridor walls, at the following locations:

a) 11:20 AM, above the 2nd floor alcohol based had rub dispenser, between Resident Room 277 and Resident Room 275;
b) 12:01 PM, at the 1st floor Employee Clock in area.

Interview with the Maintenance Director on May 20, 2024, at 12:01 PM, confirmed the unprotected penetrations of the corridor walls.

Plan of Correction - To be completed: 06/19/2024

1. The corridor walls located at the following areas have been repaired:
a) above the 2nd floor alcohol based had rub dispenser, between Resident Room 277 and Resident Room 275;
b) the 1st floor Employee Clock in area.
2. Maintenance Director or designee will audit all corridor areas for penetrations at least quarterly and repair any identified in need of repair. Findings of the audit will be reviewed by the QAPI Committee.

Date of correction is 6/19/2024.

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 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain the physical integrity of electrical receptacles, affecting one of seven smoke compartments within the facility.

Findings include:

1. Observation on May 20, 2024, at 11:15 AM, revealed the emergency outlet, within the "B" Wing Kitchenette, was physically broken.

Interview with the Maintenance Director on May 20, 2024, at 11:15 AM, confirmed the compromised physical integrity of the electrical receptacle.

Plan of Correction - To be completed: 06/19/2024

1. The outlet within the "B" wing kitchenette has been repaired.
2. Maintenance Director or designee will conduct random audits of 20 outlets monthly throughout facility and repair any in need of same. Findings of audits will be reviewed by the QAPI Committee.

Date of correction is 6/19/2024.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been verified within the previous twelve months, affecting the entire component.

Findings include,

1. Review of documentation on May 20, 2024, at 10:47 AM, revealed the facility failed to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been verified within the previous twelve months.

Interview with the Maintenance Director on May 20, 2024, at 10:47 AM, confirmed the lack of documentation verifying the quality of the diesel fuel servicing the emergency generator had been verified within the previous twelve months.

Plan of Correction - To be completed: 06/19/2024

1. Verification of the quality of the diesel fuel servicing the emergency generator has been scheduled for service, and will be done at least annually.
2. Maintenance Director or designee will schedule annual fuel quality testing at least every 12 months. Findings of the fuel quality test will be included in the Life Safety Book. NHA or designee will audit the Life Safety Book annually to verify the test result has been received and filed in the Life Safety book. Results of audit will be reported to teh QAPI Committee.

Date of correction is 6/19/2024.

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