Pennsylvania Department of Health
GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  43 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.
GREENFIELD HEALTHCARE 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 February 16, 2024, at Greenfield Healthcare 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 #490802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 16, 2024, it was determined that Greenfield Healthcare and Rehabilitation 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 one-story, Type III (200), unprotected, ordinary building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to inspect the emergency lighting for three out of twelve months.

Findings include:

Document review on February 16, 2024, at 9:23 a.m., revealed the facility failed to provide documentation for three of twelve monthly thirty-second tests for the battery back-up light.

Interview with the maintenance supervisor on February 16, 2024, at 9:23 a.m., confirmed the documentation was unavailable at the time of the survey.





 Plan of Correction - To be completed: 03/14/2024

To ensure that emergency testing is completed for battery backup lights, the following action plan will occur:
The facility is unable to retroactively correct the deficient practice for the 3 months that documentation was unavailable.
Education will be provided to the Maintenance Director by the Administrator regarding Emergency Lighting no later than February 29, 2024.
The thirty-second tests for the battery back-up lighting will occur monthly for all back-up lighting and be completed by the Maintenance Director.
An audit will be completed monthly by the Maintenance Director to ensure that testing is completed and will be monitored by the Administrator. Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

NFPA 101 STANDARD Exit Signage: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.
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 01 - Component: 01 - Tag: 0293

Based on document review and interview, the facility failed to inspect exit signage for five of twelve months.

Findings include:

Document review on February 16, 2024, at 9:20 a.m., revealed the facility failed to provide documentation for five of twelve exit signage monthly inspections.

Interview with the maintenance supervisor on February 16, 2024, at 9:20 a.m., confirmed facility failed to provide the documentation at the time of the survey.





 Plan of Correction - To be completed: 03/14/2024

The facility is unable to retroactively correct the deficient practice for the past months that documentation was unavailable.
To ensure that Exit Signage inspections will occur going forward, the following will be implemented:
Education will be provided to the Maintenance Director by the Administrator regarding Exit Signage no later than February 29, 2024.
The Maintenance Director will be responsible for ensuring that documentation is present and to verify that all Exit Signage is inspected each month to ensure proper functioning.
An audit will be completed monthly by the Maintenance Director to ensure that the Exit Signage inspection has been completed and will be monitored by the Administrator. Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

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 01 - Component: 01 - Tag: 0355

Based on observation and interview, the facility failed to meet portable fire extinguisher requirements for one of over ten portable extinguishers.

Findings include:

Observation on February 16, 2024, at 11:44 a.m., revealed the basement elevator room had a portable fire extinguisher missing two monthly inspection dates.

Interview with the maintenance supervisor on February 16, 2024, at 11:44 a.m., confirmed the deficiency.



 Plan of Correction - To be completed: 03/14/2024

To ensure that Fire Extinguisher are inspected monthly, the following will be instituted:
The portable Fire Extinguisher located in the basement elevator room has been inspected.
Education will be provided to the Maintenance Director by the Administrator regarding Portable Fire Extinguishers no later than February 29, 2024.
To ensure that all Fire Extinguishers are inspected monthly, an audit will be conducted by the Maintenance Director each month for all Fire Extinguishers to ensure that they have been inspected. And will be monitored by the Administrator. Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
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, the facility failed to install and maintain smoke barriers, per regulations, on two of two building levels.

Findings include:

Observation on February 16, 2024, at 9:00 a.m., revealed the facility had incomplete smoke barriers throughout the building.

Interview with the administrator and maintenance supervisor on February 16, 2024, at 9:00 a.m., confirmed the facility had incomplete smoke barriers throughout the building.




 Plan of Correction - To be completed: 03/14/2024

For two of two building levels, the facility will utilize the FSES to demonstrate compliance with the Fire Safety requirement for the installation and maintaining of smoke barriers for the facility.
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for two of four quarters.

Findings include:

Document review on February 16, 2024, at 9:55 a.m., revealed the facility failed to provide documentation for the following fire drill requirements:
A. (9:55 a.m.) First quarter, second shift;
B. (9:55 a.m.) First quarter, third shift;
C. (9:55 a.m.) Second quarter, first shift.

Interview with the maintenance supervisor on February 16, 2024, at 9:55 a.m., confirmed the facility failed to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 03/14/2024

For first quarter, second shift, first quarter, third shift and second quarter, first shift Fire Drills the facility is unable to retroactively correct the deficient practice for the Fire Drills.
To ensure that Fire Drills are conducted per regulatory requirements the following will occur:
Education will be provided to the Maintenance Director by the Administrator regarding Fire Drills no later than February 29, 2024.
Monthly Fire Drills will be conducted and documented no less than 1 time per shift per quarter to include weekends. The Drills will be the responsibility of the Maintenance Director and will be audited by the Administrator. Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 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, the facility failed to meet inspection and testing requirements for essential electrical systems for one of one generator.

Findings include:

Document review on February 16, 2024, at 9:33 a.m., revealed the facility failed to provide documentation for the following generator requiremetns:
A. (9:33 a.m.) Monthly generator thirty-minute under-load testing and transfer switch for nine of twelve months;
B. (9:33 a.m.) Weekly battery voltage testing.

Interview with the maintenance supervisor on February 16, 2024, at 9:33 a.m., confirmed the facility failed to provide the documentation at the time of the survey.






 Plan of Correction - To be completed: 03/14/2024

The facility is unable to retroactively correct the deficient practice for the past months that documentation was unavailable.
To ensure that inspection and testing requirements for essential electrical systems for the generator
occur the following will be completed:
Education will be provided to the Maintenance Director by the Administrator regarding inspection and testing requirements for Essential Electrical Systems no later than February 29, 2024.
The Maintenance Director will ensure that a monthly generator thirty-minute underload testing and transfer switch as well as weekly battery voltage testing will occur as per regulation.
A monthly audit will be conducted by the Maintenance Director and will be monitored by the Administrator to ensure that inspection and testing requirements for essential electrical systems for the generator will occur. Results of the audit will be presented at the monthly Quality Assurance Meeting and recommendations will be implemented.


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