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 45 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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 an Emergency Preparedness Survey completed on April 4, 2024, at Luther Woods Nursing and Rehabilitation 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# 640302
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 4, 2024, it was determined that Luther Woods Nursing And Rehabilitation 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 one story, Type III (200), unprotected ordinary building, with a partial basement, that 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: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, affecting one of two levels.

Findings include:

Document review on April 4, 2024, at 9:00 a.m., revealed documentation verifying an annual 90-minute test of the facility' s battery back-up lighting was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed the missing documentation.

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

Based on document review and interview during an onsite Revisit conducted on May 29, 2024, the following was determined:

Not Completed. Documentation verifying an annual 90-minute test of the facility's battery back-up lighting was not available at the time of survey.

Exit Interview with the Administrator and Maintenance Director on May 29, 2024, at 10:15 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/21/2024

Maintenance will complete testing by 6/21/2024. Maintenance will then audit monthly x4 then quarterly x 2.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain fire alarm system components, affecting one of two levels.

Findings include:

Document review on April 4, 2024, at 9:00 a.m., revealed the December 14, 2023, Fire alarm inspection listed the following deficiency: on the first floor, C-wing by Activities Room pull station device does not reset with key. Corrective action was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed the Fire Alarm System deficiency.

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

Based on document review and interview during an onsite Revisit conducted on May 29, 2024, the following was determined:

Not Completed. The December 14, 2023 Fire alarm inspection report listing the first floor, C-wing by the Activities Room pull station device does not reset with a key. Corrective action was not available at the time of survey.

Exit Interview with the Administrator and Maintenance Director on May 29, 2024, at 10:15 a.m., confirmed the Fire Alarm System deficiency.

Plan of Correction - To be completed: 06/20/2024

Johnson Controls is scheduled to check C Wing Pull Station on 6/20/2024. Maintenance will then audit monthly x 2, then quarterly x 4.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator.

Findings Include:

Document review on April 4, 2024, at 9:00 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a. monthly conductance testing of the generators maintenance free batteries.

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed the missing documentation.

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

Based on document review and interview during an onsite Revisit conducted on May 29, 2024, the following was determined:

a. Not Completed. The facility lacked verifying documentation of monthly conductance testing of the generators maintenance free batteries.

Exit Interview with the Administrator and Maintenance Director on May 29, 2024, at 10:15 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/16/2024

Maintenance has received the testing equipment and has been performing monthly maintenance free battery testing and documenting results. Audits will be performed monthly x 12.

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