Pennsylvania Department of Health
LUTHER WOODS NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 surveys for this facility. Please select a date to view the survey results.

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LUTHER WOODS NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on a Revisit to an Emergency Preparedness Survey completed on December 18, 2024, it was determined that Luther Woods Nursing And Rehabilitation Center was in substantial compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 640302
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 18, 2024, it was determined that Luther Woods Nursing And Rehabilitation Center was not in substantial 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 one-story, Type III (200), unprotected ordinary building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - 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.

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 observation, interview and documentation review, it was determined the facility failed to obtain required Pennsylvania Department of Health Final Occupancy Inspection approval for replacement to the facility's emergency power generator and other ESS components, affecting the entire facility.
Findings include:
1. Observation, interview and documentation review on December 18, 2024, between 8:00 a.m. and 11:30 a.m., revealed that the facility failed to "Notify In Writing" the Norristown Department of DSI of approved PA DOH Stamped Drawing Index of H-22-0230 indicating when construction has started and when construction has been completed.
Exit Interview with the Administrator, Administrator in training and Maintenance Director on December 18, 2024, at 1:45 p.m., confirmed no notification was made to the DOH Norristown Division of Safety Inspection.
Reference: 28 Pa Code 51.3. Notification (d)

Based on document review and interview, it was determined the facility failed to update facility policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

2. Document review on December 18, 2024, between 8:00 a.m., and 11:30 a.m., revealed the facility failed to provide a carbon monoxide alarm evacuation policy plan and associated staff in-service to the plan.

Exit Interview with the Administrator, Administrator in training and Maintenance Director on December 18, 2024, at 1:45 p.m., confirmed the lack of policy documentation.

Based on document review and interview, it was determined the facility failed to provide portable, accurate floor plans, affecting the entire facility.

3. Document review on December 18, 2024, between 8:00 a.m. and 11:30 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The portable plan provided at time of survey had no indication of items a, b, c, d and f (noted below). The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Exit Interview with the Administrator, Administrator in training and Maintenance Director on December 18, 2024, at 1:45 p.m., confirmed the lack of portable, accurate indicating floor plans.

*************************************

Based on document review and interview during an onsite Revisit conducted on February 11, 2025, the following was determined:

Item 1. Not Completed. Written scheduling request for occupancy inspection of new generator, has not been completed.

Exit interview with Maintenance Director on February 11, 2025, at 10:00 a.m. confirmed the online request to Norristown DSI has not been submitted at the time of Revisit.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 02/28/2025

We notified Norristown Department of DSI on 1/30/2025. We needed to gather more documentation for DSI. This documentation will be completely acquired and submitted by 2/28/25.

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 observation, document review, and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

1. Document review on December 18, 2024, between 8:00 a.m., and 11:30 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a) Annual Fuel Quality Test.
b) 3 year, 4 hour load test

2. Observation on December 18, 2024 between 11:30 a.m. and 1:45 p.m. ,revealed that the newly installed generator was in alarm for "over-cranking".

Exit Interview with the Administrator, Administrator in training, and the Director of Maintenance on December 18, 2024, at 1:45 p.m., confirmed the missing documentation and that the emergency generator was in alarm during survey.

*********************************

Based on document review and interview during an onsite Revisit conducted on February 11, 2025, the following was determined:

Item 1a. Not Completed. The facility could not provide documentation of the following test and inspection:

a) Annual Fuel Quality Test.

Exit interview with the Maintenance Director on February 11, 2025, at 10:00 a.m., confirmed the annual fuel quality test was not available at time of Revisit.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 03/12/2025

The annual fuel test is scheduled to be completed on 2/26/25. Results take up to 2 weeks to receive so they will be available to us by 3/12/25. Maintenance will keep the date and the results logged in our Generator Binder and wil ensure the fuel quality test is completed in February every year ongoing.

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