Pennsylvania Department of Health
LECOM AT PRESQUE ISLE, INC.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LECOM AT PRESQUE ISLE, INC.
Inspection Results For:

There are  41 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.
LECOM AT PRESQUE ISLE, INC. - 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 28, 2024, at Lecom at Presque Isle, Inc., 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 #530402
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on February 28, 2024, it was determined that Lecom at Presque Isle, Inc. 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 II (000), unprotected, non-combustible building, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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 provide documentation for functional tests of the battery-powered emergency lighting throughout the entire facility.

Findings include:

Document review on February 28, 2024, at 10:45 a.m., revealed the facility lacked documentation for monthly 30-second testing and annual 90-minute testing.

Interview with the maintenance supervisor on February 28, 2024, at 10:45 a.m., confirmed the facility could not provide documentation that the emergency lighting tests were completed.

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Interview with the administrator and maintenance supervisor during an Onsite Revisit Survey conducted on April 4, 2024, at 10:45 a.m., revealed the deficiency was not corrected, and the facility is in the process of ordering, scheduling, and replacing the hard-wired emergency light with battery backup lighting.










 Plan of Correction - To be completed: 05/14/2024

Facility will complete monthly 30 second and annual 90 minute testing of all battery operated emergency lighting.

Audit slip will include location, date tested, time tested start to finish, and results.
Audit will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 document review and interview, the facility failed to maintain fire alarm system components, affecting the entire facility.

Findings include:

Document review on February 28, 2024, at 10:30 a.m., revealed the facility could not provide documentation for the following testings/inspections that were to have occurred within the previous twelve months:
A) (Annual) functional fire alarm;
B) (Semi-annual) visual fire alarm.

Interview with the maintenance supervisor on February 28, 2024, at 10:30 a.m., confirmed the missing documentation.

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Interview with the administrator and maintenance supervisor during an Onsite Revisit Survey conducted on April 4,2024, at 10:28 a.m., revealed the deficiencies were not corrected, but provided a signed contract proposal to conduct the testing and inspections of the fire alarm system in the future.







 Plan of Correction - To be completed: 05/14/2024

Facility Failed to provide the necessary documentation for semi annual and annual documentation for fire alarm testing.

Fire alarm testing documentation will be completed for semi annual and annual fire alarm testing.
Facility has made contact with contractor to complete semiannual and annual testing.
Audit will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 maintain two of two generators, affecting the entire facility.

Findings include:

Document review on February 28, 2024, at 11:00 a.m., revealed the facility failed to provide documentation for the following tests:
A. (Monthly) specific gravity or conductance;
B. (Annual) fuel quality test.

Interview with the maintenance supervisor on February 28, 2024, at 11:00 a.m., confirmed the tests had not been completed.

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Interview with the administrator and maintenance supervisor during an Onsite Revisit Survey conducted on April 4, 2024, at 10:33 a.m., revealed the deficiencies were not corrected and the facility is in the process of ordering and scheduling the fuel sample testing.








 Plan of Correction - To be completed: 05/14/2024

Facility failed to provide documentation for (A) Monthly Specific gravity Conductance; (B) Annual fuel Quality Testing
Facility has purchased conductance tool for testing. Testing has begun immediately. Audit will be completed monthly and reviewed at monthly QAPI meeting

Facility will have the fuel quality results on file upon completion. Fule Quality sample has been recieved from contractor and is currently on record.


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