Nursing Investigation Results -

Pennsylvania Department of Health
BUCKTAIL MEDICAL CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BUCKTAIL MEDICAL CENTER
Inspection Results For:

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

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BUCKTAIL MEDICAL 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 23, 2022, at Bucktail Medical 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# 549602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 23, 2022, it was determined that Bucktail Medical 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 483.70(a).

This is a one story, Type II (111), protected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of one floor.

Findings include:

1. Observation on May 23, 2022, at 11:12 a.m., revealed the plaster portion of the rated ceiling assembly, located within the Staff Lounge, was damaged and portions of plaster were missing.

Exit interview with the Facility Administrator on May 23, 2022, between 12:00 p.m., and 12:30 p.m., confirmed the building construction deficiency.



 Plan of Correction - To be completed: 07/01/2022

All other plaster ceilings throughout the facility were visually inspected for damage, including missing plaster. No other problem areas were identified.
Loose plaster on the ceiling in the staff lounge was removed. New plaster and paint will be applied to the staff lounge ceiling.

Damaged plaster ceilings has been added as a quality indicator for the Quality Improvement (QI) program.

The Maintenance Director or assigned staff will inspect, document, and repair any damaged plaster ceilings throughout weekly monthly with a goal of 100% compliance.

Maintenance Director will review and report the results at the monthly QI program meeting. Monitoring and reporting will continue until a goal of 100% compliance attained and maintained for three consecutive months.

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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of one floor.

Findings include:

1. Observation on May 23, 2022, at 11:32 a.m., revealed three penetrations of the Isolation Trash Room door.

Exit interview with the Facility Administrator on May 23, 2022, between 12:00 p.m., and 12:30 p.m., confirmed the hazardous area enclosure deficiency.



 Plan of Correction - To be completed: 06/24/2022

All interior doors of the facility were inspected for penetrations, no other door penetrations were found.

The three penetrations in the Isolation Trash Room door will be filled with fire rated caulking and finished with wood putty.

Interior door penetration has been added as a quality indicator for the Quality Improvement (QI) program.

The Maintenance Director or assigned staff will inspect, document, and repair any penetrations in any interior doors throughout weekly with a goal of 100% compliance.

Maintenance Director will review and report the results at the monthly QI program meeting. Monitoring and reporting will continue until a goal of 100% compliance attained and maintained for three consecutive months.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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, it was determined the facility failed to maintain one portable fire extinguishing device, affecting one of one floor.

Findings include:

1. Observation on May 23, 2022, at 11:18 a.m., revealed the portable fire extinguisher, located within the penthouse, had not been checked since September of 2021.

Exit interview with the Facility Administrator on May 23, 2022, between 12:00 p.m., and 12:30 p.m., confirmed the fire extinguisher deficiency.




 Plan of Correction - To be completed: 06/24/2022

Inspection tags on all fire extinguishers throughout the facility were reviewed for monthly inspections. All other fire extinguisher documentation was current.

The fire extinguisher in the penthouse and in the administrative area were immediately inspected and found to be in proper working order.

Monthly fire extinguisher checks have been added as a quality indicator for the Quality Improvement (QI) program.
The Maintenance Director or assigned staff will inspect and document all monthly fire extinguisher inspections monthly with a goal of 100% compliance.

Maintenance Director will review and report the results at the monthly QI program meeting. Monitoring and reporting will continue until a goal of 100% compliance attained and maintained for three consecutive months.

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 openings in two locations, affecting one of one floor.

Findings include:

1. Observation on May 23, 2022, between 11:22 a.m., and 11:23 a.m., revealed the following:

a. 11:22 a.m., the Dietary entrance door panic hardware was damaged.
b. 11:23 a.m., the Dish Room door required adjustment to fully latch.

Exit interview with the Facility Administrator on May 23, 2022, between 12:00 p.m., and 12:30 p.m., confirmed the corridor opening deficiencies.





 Plan of Correction - To be completed: 06/24/2022

All panic hardware equipped doors throughout the facility were inspected for proper closure and latching; all other doors equipped with panic hardware are functioning properly.

The damaged dietary entrance door panic hardware will be replaced.

The dish room door panic hardware will be adjusted and/or replaced as necessary so that the door closes and latches.

Proper functioning of panic hardware equipped doors has been added as a quality indicator for the Quality Improvement (QI) program.

The Maintenance Director or assigned staff will inspect, document, and repair proper functioning of panic hardware equipped doors throughout weekly with a goal of 100% compliance.

Maintenance Director will review and report the results at the monthly QI program meeting. Monitoring and reporting will continue until a goal of 100% compliance attained and maintained for three consecutive months.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID# 549602
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on May 22, 2022, it was determined that Bucktail Medical 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.



 Plan of Correction:


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: BUILDING 02 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of one floor.

Findings include:

1. Observation on May 23, 2022, at 11:40 a.m., revealed the Resident Room door 218 was not smoke-tight.

Exit interview with the Facility Administrator on May 23, 2022, between 12:00 p.m., and 12:30 p.m., confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 06/24/2022

All resident rooms were checked to ensure they are smoke tight. No other doors were observed not to be smoke tight.

A seal will be added to the frame of resident room 218 to make the door fit smoke tight.

Checking resident room doors for smoke tight status has been added as a quality indicator for the Quality Improvement (QI) program.

The Maintenance Director or assigned staff will inspect, document, and repair resident room doors to make sure they are smoke tight weekly with a goal of 100% compliance.

Maintenance Director will review and report the results at the monthly QI program meeting. Monitoring and reporting will continue until a goal of 100% compliance attained and maintained for three consecutive months.


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