Pennsylvania Department of Health
MAJESTIC OAKS REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MAJESTIC OAKS REHABILITATION AND NURSING 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 29, 2024, at Majestic Oaks Rehabilitation and Nursing 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# 558802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2024, it was determined that Majestic Oaks Rehabilitation And Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to maintain carbon monoxide alarms located at fossil fuel-burning devices, in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

Document review on May 29, 2024 at 8:30 a.m., revealed the facility failed to adhere to the Care Facility Carbon Monoxide Alarms Standards Act in the following ways:

a) The facility failed to ensure that carbon monoxide alarms were tested/cleaned in accordance with manufacturer's specifications;
b) The facility could not provide documentation showing the batteries in carbon monoxide alarms were replaced annually.

Exit Interview with the Administrator and Maintenance Director on May 29, 2024 at 10:00 a.m., confirmed the facility did not adhere to the Care Facility Carbon Monoxide Alarms Standards Act.

Plan of Correction - To be completed: 06/15/2024

Any area with a fossil fuel burning device was noted and ensured that carbon monoxide detector in place.

Rounding worksheet made for all devices.

All devices tested / cleaned monthly

All batteries will be replaced yearly.

An audit was completed by the Maintenance Director /Designee and all carbon monoxide detectors accounted for on round sheet.

Education provided to Maintenace Director and Assistant by Administrator on ensuring that all fossil fuel burning devices have a carbon monoxide alarm located nearby and that they must be tested and cleaned monthly, and batteries replaced yearly.

Monthly rounds to occur to document that carbon monoxide alarms are working, clean and batteries are changed timely.

Random audits by the Administrator /designee once a month for 3 months to ensure carbon monoxide alarms are being monitored.

Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.

NFPA 101 STANDARD Utilities - Gas and Electric:

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.

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 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for the electrical wiring, affecting one of four levels in the facility.

Findings include:

Observation on May 29, 2024, at 9:36 a.m., revealed on the third floor, an unsecured junction box above the ceiling outside the elevators.

Exit Interview with the Administrator and Maintenance Director on May 29, 2024, at 10:00 a.m., confirmed the unsecured junction box.

Plan of Correction - To be completed: 06/14/2024

Junction Box was secured.

An audit was completed by the Maintenance Director /Designee to ensure that all junction boxes are secured.

Education provided to Maintenace Director and Assistant by Administrator on ensuring that all junction boxes are secured.

Junction box will be added to the rounds sheet to ensure being monitored.

Random audits by the Administrator /designee once week for one month then twice a month for one month and then once a month for one month to ensure that junction boxes are being monitored.

Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.

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