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

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LUTHER WOODS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  44 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 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.





 Plan of Correction - To be completed: 04/25/2024

Battery back up emergency lighting testing has been performed and will be done so and documented annually per procedural requirement. Since this is an annual test, the annual test is in the maintenance log book to be completed the 1st month, which is January, of every new year. The January annual test page is clearly marked that it is a different type of test.
NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was maintained, affecting one of two levels.

Findings include:

Document review on April 4, 2024, at 9:00 a.m., revealed the February 27, 2024, kitchen suppression system report noted the following compliance issue, which remained uncorrected at time of survey: " Range not properly protected. Needs 1- 260 nozzle removed and replaced with 2- 1F nozzles for back shelf protection. Nozzles must also be moved out to the rear perimeter. Additional fusible link detector needed over the grill. "

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed the kitchen fire suppression system deficiency.




 Plan of Correction - To be completed: 05/16/2024

Shapiro Fire Protection has been contacted to make the necessary repairs to the kitchen fire suppression system. Repair expected to be completed by 5/16/24
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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.




 Plan of Correction - To be completed: 05/25/2024

Johnson Controls was contacted to correct the Activities Room pull station issue with key not resetting. We are on their list for service but they have not come out as of today. The plan is for the correction to take place within 30 days.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain fire extinguisher inspections, affecting two fire extinguishers.

Findings include:

Observation made on April 4, 2024, at 9:00 a.m., revealed the following fire extinguisher tags were missing monthly quick-check inspections:

a. 10:15 a.m., basement boiler room.
b. On the first floor, C-wing electrical room.

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




 Plan of Correction - To be completed: 04/25/2024

Inspection tags have been corrected. Staff have been re-educated to properly locate and fill out inspection tags.
An audit will be conducted every 2 months x 2 and then quarterly x 2 to insure compliance.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on document review and interview, it was determined the facility failed to provide smoke compartments not greater than 22,500 square feet, with a travel distance not to exceed 200 feet, affecting one of four smoke compartments.

Findings include:

Observation and document review on April 4, 2024, between 8:30 a.m. and 11:00 a.m., revealed smoke compartments, front and back hallways, exceed 22,500 square feet in length.

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed the B Wing smoke compartment exceeded 22,500 square feet.




 Plan of Correction - To be completed: 04/25/2024

Ken Walters, Director of Maintenance, will contact the Department of Health to request a FSES
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to conduct annual fire door inspections, for one of one required inspection.

Findings include:

Document review on April 4, 2024, at 9:00 a.m., revealed the facility could not produce documentation showing that an annual fire door inspection was performed.

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




 Plan of Correction - To be completed: 04/25/2024

The fire door inspection has been completed. A log is now in place to document when the fire door inspections are completed.
Since this is an annual test, the annual test is in the maintenance log book to be completed the 1st month, which is January, of every new year. The January annual test page is clearly marked that it is a different type of test.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical equipment, affecting one of two levels.

Findings Include:

1. Observation on April 4, 2024, at 10:00 a.m., on the first floor, in the kitchen hall, the electrical panel was blocked by various items.

Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the obstructed electrical panels.

~Refer to the 2011 edition of NFPA 70, 110.26 (A) (1)

2. Observation on April 4, 2024, at 11:00 a.m., revealed corridor electrical panels were not locked to prevent unauthorized access, on the first floor, A-wing by Nurse Station.

~Refer to the 2011 edition of NFPA 70 National Electrical Code, Section 460.

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




 Plan of Correction - To be completed: 04/25/2024

1.All Obstruction were removed on 4/4/2024.
2.New locks were installed on the electrical boxes on A Wing on 4/5/2024
An audit will be completed weekly x 4 then monthly x2 then quarterly x 2 to insure compliance.
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 Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, affecting one generator.

Findings include:

Observation on April 4, 2024, at 11:00 a.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosure.

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed there was not a remote manual stop switch located outside of the generator enclosure.




 Plan of Correction - To be completed: 05/24/2024

GenServe had the Emergency Stop Switch. They have shipped it to to the facility. It will be installed by 5/25/24.
Once it is installed we will audit it's compliance on a weekly basis. The data will be kept in our Maintenance Log.
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 Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain alarm annunciation for the Essential Electrical System, affecting the entire building.

Findings Include:

Observation on April 4, 2024, at 11:30 a.m., revealed a remote annunciator panel at a continuously monitored location during the hours of operation could not be located within the facility, for the emergency generator.

Exit Interview with the Administrator and Maintenance Director on April 4, 2024, at 12:00 p.m., confirmed emergency generator components were not monitored.




 Plan of Correction - To be completed: 05/25/2024

GenServe had the Annunciator Panel. They have shipped it to the facility. It will be installed by 5/25/24.
Once it is installed we will audit it's compliance on a weekly basis. The data will be kept in our Maintenance Log.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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.





 Plan of Correction - To be completed: 04/25/2024

Equipment was purchased to do the required testing for the Emergency Generator. Monthly tests are now being performed by Maintenance and logged as required.
An audit will be performed monthly x 2 then quarterly x 2 to ensure compliance.

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