Pennsylvania Department of Health
IVY HILL POST ACUTE NURSING & REHABILITATION LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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IVY HILL POST ACUTE NURSING & REHABILITATION LLC - 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 June 24, 2024, at Ivy Hill Post Acute Nursing and Rehabilitation LLC, 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 #591902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 24, 2024, it was determined that Ivy Hill Post Acute Nursing and Rehabilitation, LLC, 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of three floors.

Findings include:

1. Document review on June 24, 2024, at 9:30 a.m., revealed the June 18, 2024, Sprinkler Inspection Report listed the following deficiency: " Third Stair tower by maintenance office stair on the second floor inside oxygen closet inspector's test leaking, " evidence of correction was not available at time of survey:

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed the sprinkler system deficiency.

2. Observation on June 24, 2024, at 11:05 a.m., revealed a sprinkler with a missing escutcheon, maintenance shop on the first floor.

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed the missing escutcheon.

Plan of Correction - To be completed: 07/18/2024

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.
1. Facility repaired deficiencies noted in sprinkler inspection report, sprinkler on second floor oxygen closet (at 3rd staircase) is in good working order. Facility repaired missing sprinkler head escutcheon ring the maintenance shop.
2. NHA/ Designee completed initial audits of sprinkler heads and reviewed most recent sprinkler inspection report to ensure facility's sprinkler system is in compliance.
3. NHA / Designee educated Maintenance staff on requirements to maintain a functioning sprinkler system.
4. NHA / Designee will complete a random audit weekly x 4 then Monthly x2 to ensure sprinkler heads have a properly fitting escutcheon ring. Results will be brought to Monthly QAPI Meeting for further recommendations.

NFPA 101 STANDARD Corridor - Doors:

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 ensure that corridor doors were maintained to resist the passage of smoke, affecting one of three floors.

Findings include:

Observation on June 24, 2024, at 11:40 a.m., revealed, on the third floor, room 312 corridor door failed to close and latch when tested.

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed the corridor door failed to latch.

Plan of Correction - To be completed: 07/18/2024

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.
1. Facility repaired Third Floor (Room 312) corridor door, corridor door is in good working order and can positively latch.
2. NHA / Designee Completed initial Audits of corridor Doors to ensure they are in good working order.
3. NHA / Designee educated Maintenance staff on the requirements to ensure that corridor doors are maintained to resist the passage of smoke.
4. NHA / Designee will complete audits of corridor doors weekly x4 then monthly x2 to ensure they are maintained to resist the passage of smoke. Results will be brought to Monthly QAPI Meeting for further recommendations.

NFPA 101 STANDARD Fire Drills:

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, it was determined the facility failed to ensure fire drills were conducted quarterly for two of twelve required drills.

Findings include:

Document review on June 24, 2024, at 9:30 a.m., revealed the facility could not provide documentation that fire drills had been conducted for the following times:

a. Second quarter- Third shift.
b. Third quarter- Second shift.

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed the missing fire drills.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain designated smoking areas, affecting one of three floors.

Findings include:

Observation on June 24, 2024, at 10:35 a.m., revealed, the designated smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area and not in the provided ash receptacles. This area contains combustible leaves and mulch.

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed the discarded cigarette butts.

Plan of Correction - To be completed: 07/18/2024

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. Facility Removed Cigarette butts from designated smoking area.
2. NHA / Designee Educated staff to monitor residents ensuring they place cigarette butts in the provided ash receptacles. And educated activities staff and residents who smoke on the hazards of dropping ash or cigarette butts on the ground.
3. NHA / Designee will conduct audits of designated smoking area Weekly x 4 then monthly x2 to ensure the smoking area is properly maintained.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient bed locations, affecting one of three floors.

Findings include:

Document review on June 24, 2024, at 9:30 a.m., revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested as required for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity.
b. correct polarity of the hot and neutral connections.
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

*The facility failed to record the (b) polarity, and (c.) retention portion of receptacle testing on the second floor patient bed locations.

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed testing of electrical receptacles was incomplete.

Plan of Correction - To be completed: 07/18/2024

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. Facility conducted an annual inspection of receptacles which include the testing of the physical integrity, correct polarity, and retention force of grounding blade.
2. NHA / Designee Educated Maintenance staff on requirements to inspect receptacles annually including Visual inspection of physical integrity, Correct Polarity, and retention force of grounding blade.
3. NHA / Designee will audit inspection results of annual receptacle testing to ensure compliance of receptacles.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting three of three levels.

Findings include:

Observations on June 24, 2024, revealed the following electrical deficiencies:

a. 11:20 a.m.. on the first floor, PT- fridge plugged into power strip.
b. 11:30 a.m., on the first floor, RNAC office- fridge and microwave plugged into power strip.
c. 11:45 a.m., on the third floor, Staff Development- extension cord plugged into power strip.
d. 11:50 a.m., on the third floor, by room 300, window AC unit plugged into extension cord.
e. 11:55 a.m., on the second floor, by room 200, window AC unit plugged into extension cord.
f. 11:50 a.m., on the second floor, by room 231, window AC unit plugged into extension cord.

Exit Interview with the Administrator and Maintenance Director on June 24, 2024, at 12:45 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 07/18/2024

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. Facility Removed power cords / Power strips from the first-floor PT fridge, the first-floor RNAC office, the third-floor staff development office, the unit by room 300, the unit by 200, and the unit by 231.
2. NHA / Designee Conducted house-wide audit of electrical equipment to ensure no unauthorized use of power strips or power cords.
3. NHA / Designee educated staff on Facility Policy prohibiting unauthorized use of Power cords / Power strips in a patient care vicinity, and non-patient care vicinities.
4. NHA / Designee will conduct a random audit weekly x 4 then Monthly x2 to ensure there is no unauthorized usage of power cords or power strips in the facility. Results will be brought to Monthly QAPI Meeting for further recommendations.

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