Nursing Investigation Results -

Pennsylvania Department of Health
SMITH HEALTH CARE, LTD.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SMITH HEALTH CARE, LTD.
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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SMITH HEALTH CARE, LTD. - 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 January 15, 2020, at Smith Health Care LTD, 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 # 453102
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on January 15, 2020, it was determined that Smith Health Care LTD 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 483.70(a).

This is a two story, Type V (111) protected, wood-frame structure, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain the exit discharge, affecting one of four smoke compartments.

Findings include:

1. Observation on January 15, 2020, at 11:35 a.m., revealed the exit discharge located exit door #3 did not lead occupants safely to the public way.

Exit interview with the facility representatives #1 and #2, on January 15, 2020, at 11:50 a.m., confirmed the exit discharge.




 Plan of Correction - To be completed: 02/14/2020

Exit leads to a 4ft. by 5 ft. concrete pad surrounded by a 4 in. grassy area.
In Nov.-Dec. 2019 emergency repairs were made to underground pipes and due to rainy weather, area was covered with gravel until Spring when area will be restored to full grass.
Date of completion: 02/14/202
A temporary hard-surfaced walk way will be made from cement pad to drive way until we are able to restore to original grass ground covering.
Date of Completion: 02/21/2020
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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors, affecting two of four smoke compartments.

Findings include:

1. Observation on January 15, 2020, between 10:25 a.m. and 11:35 a.m., revealed the following corridor doors were being held open with trash receptacles:

a. 10:25 a.m. - Room #1.
b. 10:40 a.m. - Room #7.
c. 11:10 a.m. - Personal Laundry.

Exit interview with the facility representatives #1 and #2, on January 15, 2020, at 11:50 a.m., confirmed the corridor door obstructions.




 Plan of Correction - To be completed: 02/14/2020

Resident and room doors will be fixed so that door will remain open with no propping.
Facility designee will do random walk-throughs to monitor door status.
Facility designee will submit report of findings to Q.A. quarterly.
Date of completion: 02/14/2020

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - 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 maintain electrical wiring and equipment, affecting two of four smoke compartments.

Findings include:

1. Observation on January 15, 2020, between 10:30 a.m. and 11:25 a.m., revealed:

a. 10:30 a.m. - The bed located in resident room #4 was placed against an electrical receptacle.

b. 11:25 a.m. - The Dietary Storage room had a chest freezer plugged into an unauthorized extension cord.

Exit interview with the facility representatives #1 and #2, on January 15, 2020, at 11:50 a.m., confirmed the bed against an electrical receptacle and an unauthorized extension cord.




 Plan of Correction - To be completed: 02/14/2020

1a. Resident room #4 electrical receptacle had plate put on
b. The unauthorized extension cord was disposed of immediately and the chest freezer was removed,
and it is no longer in use.
2a. All resident rooms checked in Personal Care and found to be incompliance with regard to the
Electrical receptacles.
b. All extension cords meet regulatory requirements.
Facility designee will monitor resident rooms for regulatory compliance regarding electrical receptacles and will submit report to Q.A. quarterly.
Facility designee will submit report monthly to Q.A. regarding extension cord compliance.
Date of completion: 02/14/202


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