Pennsylvania Department of Health
CHAMBERSBURG SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHAMBERSBURG SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  40 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.
CHAMBERSBURG SKILLED 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 May 21, 2024, at Chambersburg Skilled 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 - Component: 01 - Tag: 0000


Facility ID# 640702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2024, it was determined that Chambersburg Skilled Nursing and Rehabilitation Center 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 one-story, Type III (211), protected ordinary structure, without a basement, which 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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system in a continuously reliable operating condition and to maintain a supply of spare sprinkler heads, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on May 21, 2024, between 12:25 PM and 1:30 PM, revealed sprinkler heads lacking an escutcheon, in the following locations:

a) 12:25 PM, Medbridge Nurses' Station Staff Restroom;
b) 1:30 PM, within the Kitchen, by the dish washing sink.

Interview with the Maintenance Director on May 21, 2024, at 1:30 PM, confirmed the missing escutcheons.

2. Observation on May 21, 2024, at 1:10 PM, revealed the facility lacked a supply of sidewall orientated sprinkler heads.

Interview with the Maintenance Director on May 21, 2024, at 1:10 PM, confirmed the lack of spare sidewall orientated sprinkler heads.



 Plan of Correction - To be completed: 06/28/2024

1. and 2. Maintenance Director bought a supply of spare sprinkler heads/escutcheons for the facilities sprinklers and supplied escutcheons in Medbridge nurses' station staff restroom and in the kitchen by the dish-washing sink.

3. Maintenance department will be educated on the standards of ensuring the facility has spare supply of sprinkler heads/escutcheons.

4. Maintenance or facility designee will audit the facilities sprinkler heads weekly x2 for 2 months, then every 60 days throughout the year and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD Corridor - Doors: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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor doors, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on May 21, 2024, at 1:20 PM, revealed an unprotected penetration on the door, to the Environmental Services Account Manager's Office, where the automatic closing hardware was installed.

Interview with the Maintenance Director on May 21, 2024, at 1:20 PM, confirmed the unprotected penetration of the corridor door.





 Plan of Correction - To be completed: 06/28/2024

1 and 2. Maintenance Director placed a bolt through the identified unprotected penetration on the door in the Environmental Services Account Managers office where the automatic closing hardware was installed.

3. Maintenance department will be educated on the standards of ensuring the facility's corridor doors are protected from penetration.

4. Maintenance or facility designee will audit two out of the four facility units' corridor doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to prevent unauthorized access to electrical panels, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on May 21, 2024, at 1:35 PM, revealed electrical panel AC2, located at Nurses' Station 2, was unlocked and available to unauthorized access.

Interview with the Director of Maintenance on May 21, 2024, at 1:35 PM, confirmed the electrical panel was not protected from unauthorized access.



 Plan of Correction - To be completed: 06/28/2024

1 and 2. Maintenance Director locked the access to electrical panel located at nurses' station 2 to ensure unauthorized access protection.

3. Maintenance department will be educated on the standards to ensure all unauthorized access to electrical panels are locked.

4. Maintenance or facility designee will audit facilities electrical panels/unauthorized access areas to ensure areas are locked weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to provide documentation verifying corrective action regarding failures documented on fire damper inspection reports, affecting four of six smoke compartments within the component.

Findings include:

1. Review of documentation on May 21, 2024, at 10:15 AM, revealed the following fire dampers were marked as deficient on the May 2023 fire damper inspection report, and no corrective action could be verified:

a) Damper #1118;
b) Damper #1145;
c) Damper #1150;
d) Damper #1201.

Interview with the Maintenance Director on May 21, 2024, at 10:15 AM, confirmed no corrective action could be verified in regard to the failed fire dampers.



 Plan of Correction - To be completed: 06/28/2024

1 and 2. Maintenance Director contracted Eastern Time, Inc. to revisit facility to inspect four of the six fire dampers, damper #1118 (health concern), #1145 (health concern), #1150 (no access), and #1201 (no access) and will repair any failed fire dampers.

3. Maintenance department will be educated on the standards of the facilities fire damper inspection.

4. Maintenance or facility designee will audit facilities fire damper inspection located in the life safety book on an annual basis to confirm fire damper reports are still available for review and results of the audit will be reported to the QA Committee.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port