Pennsylvania Department of Health
PINE RUN HEALTH CENTER
Building Inspection Results

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PINE RUN HEALTH CENTER
Inspection Results For:

There are  53 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.
PINE RUN HEALTH 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 March 28, 2024, at Pine Run Health 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 # 680502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed March 28, 2024, it was determined that Pine Run Health 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 five-story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


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 maintain and inspect fire doors, affecting the entire facility.

Findings include:

Document review on March 28, 2024, at 9:45 a.m., revealed the facility could not provide documentation of any fire door inspections.

Exit interview with the Administrator and Maintenance Director on March 28, 2024, at 12:00 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 05/27/2024

Plan of Correction 0761 (Maintenance, Inspection & Testing - Doors)

1) All Fire doors in Health Center will be inspected with measuring tool and instituted checklist by April 29, 2024. Fire doors will be inspected on an annual basis and documentation to be kept in safety binder.

2) The Director of Environmental Services or designee will inspect all Fire doors in Health Center with measuring tool and inspection checklist on an annual basis to ensure compliance.

3) The Director of Environmental Services or designee will provide education to maintenance staff members on how to properly inspect all Fire doors in Health center with measuring tool and inspection checklist to ensure compliance.

4) The Director of Environmental Services or designee will conduct an audit of all Fire doors on a quarterly basis to ensure Fire door compliance. Audits results will be brought to the Quality Assurance meeting for review and recommendations.


5) Date of completion is scheduled for May 27, 2024.



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

Findings include:

Document review on March 28, 2024, at 9:45 a.m., revealed the facility could not produce documentation of the following:

a. Monthly testing of battery conductance;
b. Annual fuel quality test.

Exit interview with the Administrator and Maintenance Director on March 28, 2024, at 12:00 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 05/27/2024

Plan of Correction 0918 (Electrical Systems)

1) Facility emergency generator battery conductance testing was completed, and annual fuel quality test was also completed. Date of completion for battery conductance test was April 9, 2024 and March 25, 2024 for the fuel quality test.

2) The Director of Environmental Services or Designee will test emergency generator battery on a monthly basis and fuel quality test on an annual basis. Documentation will be kept in Inspection Binder.

3) The Director of Environmental Services or designee will provide education to maintenance staff members on testing battery conductance and storing documentation for fuel quality test.

4) The Director of Environmental Services or designee will conduct an audit of the Inspection Binder on a quarterly basis to ensure battery conductance compliance and annually to ensure fuel quality compliance. Audits results will be brought to the Quality Assurance meeting for review and recommendations.


5) Date of completion is scheduled for May 27, 2024.


NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain gas and cylinder storage rooms, affecting one of four levels in the facility.

Findings include:

Observation on March 29, 2024, at 11:38 a.m., revealed, on the second floor, Oxygen Storage Room lacked signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Exit interview with the Administrator and Maintenance Director on March 28, 2024, at 12:00 p.m., confirmed the lack of signage.



 Plan of Correction - To be completed: 05/27/2024

Plan of Correction 0923 (Gas Equipment Cylinder and Container Storage)

1) Oxygen Storage door on the second floor of the Health Center now has appropriate caution signage. This was completed on April 8, 2024

2) An audit was conducted of all Oxygen Storage doors and none were found to be out of compliance.

3) The Director of Environmental Services or designee will provide education to maintenance staff members on proper Oxygen Storage door caution signage.

4) The Director of Environmental Services or designee will conduct an audit of all Oxygen Storage doors on a monthly basis and will keep documentation in Inspection Binder. Audits results will be brought to the Quality Assurance meeting for review and recommendations.


5) Date of completion is scheduled for May 27, 2024.


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