Pennsylvania Department of Health
HANOVER HALL FOR NURSING AND REHABILITATION
Building Inspection Results

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HANOVER HALL FOR NURSING AND REHABILITATION
Inspection Results For:

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HANOVER HALL FOR NURSING AND REHABILITATION - 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 March 28, 2024, at Hanover Hall for Nursing and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: 'A' BLDG - Component: 01 - Tag: 0000


Facility ID #590102
Component 01
"A" Building

Based on a Medicare/Medicaid Recertification Survey completed on March 28, 2024, it was determined that Hanover Hall for Nursing 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 two-story, Type V (111), protected wood frame structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Number of Exits - Story and Compartment: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.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: 'A' BLDG - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide two exits, remote from each other, on each floor of the component, affecting one of two floors within the component.

Findings include:

1. Observation on March 28, 2024, at 12:10 PM, revealed the 2nd floor lacked two remote exits.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the 2nd floor did not have two remote exits.



 Plan of Correction - To be completed: 05/06/2024

1. No adverse events occurred as a result of this deficiency.
2. The facility requests an FSES be conducted by DSI.

NFPA 101 STANDARD Emergency Lighting: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.
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: 'A' BLDG - Component: 01 - Tag: 0291

Based on document review, observation and interview, it was determined the facility failed to provide documentation of monthly and annual testing, and lacked installed battery back-up emergency lighting at the transfer switch, affecting the entire component.

Findings include:

1. Review of documentation on March 28, 2024, between 8:30 AM and 10:30 AM, revealed the facility failed to provide documentation, verifying monthly and annual testing of installed battery back-up emergency lighting, at the dedicated generator and transfer switch, for elevator machinery.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the lack of documentation.


2. Observation on March 28, 2024, at 10:40 AM, revealed the ATS switch for the emergency power generator (35 KW), in the Boiler Room, lacked an installed battery back-up emergency light.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the ATS switch lacked an installed battery back-up emergency light.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern. Current generator was audited and working properly; documentation completed.
2. Facility is installing battery back-up lighting in boiler room. Monthly and annual inspections added to TELS work maintenance system.
3. Maintenance Director/designee will complete monthly audits of emergency lighting documentation quarterly to ensure compliance. Results will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: 'A' BLDG - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain emergency generator signage, which serves the entire component.

Findings include:

1. Observation on March 28, 2024, between 10:35 and 10:38 AM, revealed the emergency generator's remote manual stop station lacked identifying signage, at the following locations:

a. 10:35 AM, 35 KW (essential power);
b. 10:38 AM, 45 KW (elevator equipment only).

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the emergency generator remote stop station signage was missing.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern.
2. Facility has ordered appropriate signage to identify generator
3. Maintenance director will complete visual audits monthly x2, and then quarterly to ensure signage is in place

NFPA 101 STANDARD Features of Fire Protection - Other: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.
Features of Fire Protection - Other
List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection 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.
Chapter 15 (NFPA 99)
Observations:
Name: 'A' BLDG - Component: 01 - Tag: 0932

Based on observation and interview, it was determined the facility failed to maintain Fire Department Connection signage, which serves the entire component.

Findings include:

1. Observation on March 28, 2024, at 12:10 PM, revealed the Fire Department Connection, for the installed sprinkler system, lacked identifying signage.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the lack of Fire Department Connection signage.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern.
2. Facility has ordered appropriate signage to identify Fire Department Connection
3. Maintenance director will complete visual audits monthly x2 months then quarterly to ensure signage is in place.

Initial comments:Name: B,C,D BLDG - Component: 02 - Tag: 0000


Facility ID #590102
Component 02
Main Building-B, C, D Wings

Based on a Medicare/Medicaid Recertification Survey completed on March 28, 2024, it was determined that Hanover Hall for Nursing 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 two-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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: B,C,D BLDG - Component: 02 - Tag: 0291

Based on document review, observation and interview, it was determined the facility failed to provide documentation of monthly and annual testing, and lacked installed battery back-up emergency lighting at the transfer switch, affecting the entire component.

Findings include:

1. Review of documentation on March 28, 2024, between 8:30 AM and 10:30 AM, revealed the facility failed to provide documentation, verifying monthly and annual testing of installed battery back-up emergency lighting, at the dedicated generator and transfer switch, for elevator machinery.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the lack of documentation.


2. Observation on March 28, 2024, at 10:40 AM, revealed the ATS switch for the emergency power generator (35 KW), in the Boiler Room, lacked an installed battery back-up emergency light.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the ATS switch lacked an installed battery back-up emergency light.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern. Current generator was audited and working properly; documentation completed.
2. Facility is installing battery back-up lighting in boiler room. Monthly and annual inspections added to TELS work maintenance system.
3. Maintenance Director/designee will complete monthly audits of emergency lighting documentation x3 months, and then quarterly to ensure compliance. Results will be reviewed at QAPI to ensure compliance.

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: B,C,D BLDG - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins, on two of seven smoke zones within the component.

Findings include:

1. Observation on March 28, 2024, between 11:00 AM and 11:40 AM, revealed hazardous area doors exceeded minimum gap margins, at the following locations:

a. 11:00 AM, basement, Soiled-Utility Room door, at the top and latch side, exceeded 3/16 inch;
b. 11:40 AM, 2nd floor, by Nurses' Station, at the top, exceeded 3/16 inch.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed hazardous area doors exceeded the allowed gap margins.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern.
2. Facility has contacted a vendor to re-hang the doors to close the gaps. This is scheduled for 4/17/24.
3. Maintenance Director/designee will complete weekly audits of utility, storage, soiled utility room, and stairwell doors x4 weeks, and then quarterly thereafter. Results will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system, to be free of obstructions, and the sprinkler piping system, to be free of extraneous weight, affecting five of seven smoke components of the component.

Findings include:

1. Observation on March 28, 2024, at 11:00 AM, revealed the basement Laundry Room Dryer Chase had 2 sprinkler heads covered with debris.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed sprinkler heads were obstructed with debris.


2. Observation on March 28, 2024, between 11:30 AM and 12:40 PM, revealed various wires laying across the sprinkler pipes, at the following locations:

a. 11:30 AM, 2nd floor, above ceiling, by elevator, flex conduit;
b. 11:33 AM, 2nd floor, C Hall, above ceiling, by Resident Room 231, ceiling tiles and wires;
c. 12:30 PM, 1st floor, above ceiling, above double doors, by B1 Nurses' Station, various wires;
d. 12:40 PM, 1st floor, C1 Hall, above ceiling, by Resident Room 130, various wires and ceiling tiles.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed various wires laying across sprinkler pipes.



 Plan of Correction - To be completed: 05/06/2024

1. Sprinkler heads in laundry room were cleaned. Wiring on various floors across the sprinkler pipes was removed.
2. Maintenance director will remind on-site vendors to ensure appropriate clean up and installation around, not on, sprinkler systems/pipes. Above ceiling inspections will be completed after above ceiling work.
3. Maintenance Director will complete random audits of three areas of the building weekly x4 weeks to ensure items are not on sprinkler pipes. Sprinkler heads will be on a regular cleaning schedule. Audits will be done quarterly to ensure sprinkler heads are free of debris. Results will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: B,C,D BLDG - Component: 02 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain emergency generator signage, which serves the entire component.

Findings include:

1. Observation on March 28, 2024, between 10:35 and 10:38 AM, revealed the emergency generator's remote manual stop station lacked identifying signage, at the following locations:

a. 10:35 AM, 35 KW (essential power);
b. 10:38 AM, 45 KW (elevator equipment only).

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the emergency generator remote stop station signage was missing.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern.
2. Facility has ordered appropriate signage to identify generator
3. Maintenance director will complete visual audits monthly x2 months and then quarterly thereafter to ensure signage is in place

NFPA 101 STANDARD Features of Fire Protection - Other: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.
Features of Fire Protection - Other
List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection 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.
Chapter 15 (NFPA 99)
Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0932

Based on observation and interview, it was determined the facility failed to maintain Fire Department Connection signage, which serves the entire component.

Findings include:

1. Observation on March 28, 2024, at 12:10 PM, revealed the Fire Department Connection, for the installed sprinkler system, lacked identifying signage.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 28, 2024, at 1:15 PM, confirmed the lack of Fire Department Connection signage.



 Plan of Correction - To be completed: 05/06/2024

1. Facility cannot retroactively correct this concern.
2. Facility has ordered appropriate signage to identify Fire Department Connection
3. Maintenance director will complete visual audits monthly x2 months and then quarterly thereafter to ensure signage is in place.


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