Nursing Investigation Results -

Pennsylvania Department of Health
QUALITY LIFE SERVICES - WESTMONT
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUALITY LIFE SERVICES - WESTMONT
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - WESTMONT - 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 14, 2022, at Quality Life Services Westmont, 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# 680102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 14, 2022, it was determined that Quality Life Services Westmont, 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 483.70(a).

This is a one-story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined that the facility failed to maintain an unobstructed means of egress in one instances, affecting one of three smoke compartments.

Findings include:

1. Observation on June 14, 2022, at 11:10 a.m., revealed the exit access in the secondary shower, was blocked by miscellaneous storage, preventing an unobstructed means of egress.

Interview with the Facility Administrator and the Maintenance Director on June 14, 2022, at 12:30 p.m., confirmed the means of egress deficiency.




 Plan of Correction - To be completed: 07/30/2022

1. To ensure that the deficiency does not recur, the items in the secondary shower room were moved to provide a means of egress to the back of the room.
2. To ensure egress to back of room in secondary shower, the Maintenance Director will complete a monthly audit for 3 months.
The audit results will be reported to Quality Assurance Performance Improvement Meeting. The Nursing Home Administrator and or Designee will monitor for compliance.
Compliance Date is July 30, 2022

NFPA 101 STANDARD Emergency Lighting: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.
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 documentation review, observation, and interview, it was determined the facility failed to maintain emergency lighting in one instances, affecting the entire facility.

Findings Include:

1. Observation and documentation review on June 14, 2022, at 9:30 a.m., revealed the facility failed to perform an annual 90 minute test of the battery backup lighting in the past 12 months. The most recent annual 90 minute test of the battery backup lighting was performed in September 2020.

Interview with the Facility Administrator and the Maintenance Director on June 14, 2022, at 12:30 p.m., confirmed the emergency light deficiency.



 Plan of Correction - To be completed: 07/30/2022

1. To ensure that the deficiency does not recur, the Maintenance Director immediately performed 90 minute testing of the battery backup lighting. Documentation was completed on this.
2. To ensure the emergency back-up lighting illuminates, the Maintenance Director and or Designee will test monthly and annually as required and audit monthly for 3 months.

The audit results will be reported to Quality Assurance Performance Improvement meeting. The Nursing Home Administrator or Designee will monitor for compliance.
Compliance date is July 30, 2022

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting three of three smoke compartments.

Findings include:

1. Observation on June 14, 2022, revealed the following automatic sprinkler system deficiencies:

a) 11:13 a.m., the facility failed to maintain storage below the eighteen inch automatic sprinkler plane in the nurse station med room;
b) 11:55 a.m., the fire department connection was blocked by miscellaneous storage.


Interview with the Facility Administrator and the Maintenance Director on June 14, 2022, at 12:30 p.m., confirmed the automatic sprinkler system defciencies.




 Plan of Correction - To be completed: 07/30/2022

1. To ensure that the deficiency does not recur, the items surpassing the eighteen inch were immediately removed in the nursing med room. In addition, items blocking the fire department connection were also immediately removed.
2. To ensure that the automatic sprinkler system is maintained, the Maintenance Director and or Designee will complete a monthly audit for 3 months of the physical environment for the nursing medication room for items to be placed below the eighteen inch line in addition to items not blocking the fire department connection.
The audit results will be reported to the Quality Assurance Performance Improvement meeting. The Nursing Home Administrator or Designee will monitor for compliance.
Compliance date is July 30, 2022
NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 portable fire extinguishers in one instance, affecting the entire facility.

Findings include:

1. Observation on June 14, 2022, at 11:35 a.m., revealed the elevator equipment room was not equipped with a portable fire extinguisher.

Interview with the Facility Administrator and the Maintenance Director on June 14, 2022 at 12:30 p.m., confirmed the portable fire extinguisher deficiency.




 Plan of Correction - To be completed: 07/30/2022

1. To ensure that the deficiency does not recur, fire extinguishers were ordered and placed for generator room.
2. To ensure that the deficient practice does not recur, the Maintenance Director and or Designee will complete a monthly audit for 3 months for the placement of the fire extinguisher for the generator room.
The audit results will be reported to the Quality Assurance Performance Improvement meeting. The Nursing Home Administrator or Designee will monitor for compliance.
Compliance date is July 30, 2022
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 documentation review and interview, it was determined the facility failed to maintain the emergency generator in one instance affecting the entire facility. Maintenance shall be in accordance with ... NFPA 99, 6.4.1.1.15

Findings include:

1. Review of documentation on June 14, 2022 at 9:20 a.m., revealed the facility failed to provide the required natural gas reliability letter.

Interview with the Facility Administrator and the Maintenance Director on June 14, 2022, at 12:30 p.m., confirmed the required natural gas reliability letter was not available at the time of survey.
Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shale be accordance with NFPA 110, 8.4.6.

Findings include:

1. Review of documentation on September 3, 2021, at 9:30 a.m., revealed the facility lacked documentation to confirm the monthly testing/function of the automatic transfer switch.

Interview with the Facility Administrator and the Maintenance Director on June 14, 2022, at 12:30 p.m., confirmed the facility lacked documentation of monthly testing/function of the automatic transfer switch.









 Plan of Correction - To be completed: 07/30/2022

1. To ensure that the deficiency does nor recur, testing for function of automatic transfer switch for generator will be documented on a monthly basis.
2. To ensure that the deficient practice does not recur, the Maintenance Director or Designee will complete a monthly audit for 3 months for documentation of length of time for transfer switch.
The audit results will be reported to the Quality Assurance Performance Improvement meeting. The Nursing Home Administrator or Designee will monitor for compliance.
Compliance date is July 30, 2022

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