Nursing Investigation Results -

Pennsylvania Department of Health
QUAKERTOWN CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUAKERTOWN CENTER
Inspection Results For:

There are  34 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.
QUAKERTOWN 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 12, 2022, at Quakertown 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# 691102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 12, 2022, it was determined that Quakertown 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 II (000), unprotected non-combustible construction, 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 01 - Component: 01 - Tag: 0353
Based on observation and interview it was determined the facility failed to maintain sprinkler system components, affecting two of five smoke compartments.

Findings include:

1. Observation on May 12, 2022, between 10:50 am and 11:00 am. revealed sprinklers with buildup of dust and debris in the following locations:

a. 10:50 am, kitchen walk-in cooler.
b. 11:00 am, laundry, behind dryers.

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the buildup on the sprinklers.

2. Observation on May 12, 2022, at 11:30 am, revealed, in resident room 114, was a gap around the sprinkler, which could delay activation of the sprinkler.

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the opening.



 Plan of Correction - To be completed: 06/20/2022

1) The dust and debris has been removed from the sprinklers in the kitchen walk-in and the laundry behind the dryers to ensure no delay or hindrance of the proper operation of the sprinkler heads. 2) The ceiling tile around the sprinkler in room 114 has been replaced to remove the gap from around the sprinkler. The Maintenance Director or designee will perform monthly random audits to ensure the sprinkler heads remain in an unloaded state and that there are no gaps present. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls to resist the transfer of smoke, affecting the entire facility.

Findings include:

1. Observation on May 12, 2022, at between 10:30 am and 12:00 pm, revealed, throughout the facility, multiple unsealed penetrations of the corridor walls where devices had been removed from the walls

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the corridor wall penetrations.




 Plan of Correction - To be completed: 06/20/2022

The unsealed penetrations in the corridors have been sealed with an UL rated through wall penetration stop system, UL# W-L-4046 and a copy of the approved system will be kept in the life safety manual. The Maintenance Director or designee will perform monthly random audits to ensure the corridor walls are free of penetrations. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372
Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls affecting four of five smoke compartments.

Findings include:

1. Observation on May 12, 2022, between 11:15 am and 11:50 am, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 11:15 am, above smoke doors by social services office, around data wires.
b. 11:20 am, above smoke doors by room N1, around data wires.
c. 11:50 am, above smoke doors by room S1, around data wires.

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the unsealed penetrations.



 Plan of Correction - To be completed: 06/20/2022

The penetrations above the smoke doors around the data wires at the Social Services office, by room N1 and by room S1 have been sealed with an UL rated through wall penetration stop system, UL# W-L-4046 and a copy of the approved system will be kept in the Life Safety Manual. The Maintenance Director or designee will perform monthly random audits to ensure there are no penetrations of the smoke barrier walls. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
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 documentation review and interview, it was determined the facility failed to maintain fire rated door openings.

Findings include:

1. Document review on May 12, 2022, at 9:20 am, revealed, the Annual Fire Door Inspection report listed 13 rated doors as deficient. The repairs remained uncorrected at time of survey.

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the incomplete repairs to the rated door assemblies.



 Plan of Correction - To be completed: 07/11/2022

The Annual Fire Door Inspection report performed April 18, 2022 revealed 13 doors in need of replacement. Center had vendor out on May 10, 2022 to provide a quote and order to replace the doors. Center will be submitting a Time-Limited Waiver.
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 the emergency generators, affecting two of twelve monthly inspections.

Findings include:

1. Document review on May 12, 2022, at 9:45 am, revealed the facility lacked documentation showing the following required emergency generator maintenance items had been conducted:

a. monthly load test since February 18, 2022.
b. monthly transfer switch operation since February 18, 2022, due to faulty transfer switch.

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the missing documentation.



 Plan of Correction - To be completed: 06/20/2022

Monthly load test was performed May 13, 2022. ATS was replaced on May 12, 2022. Monthly load testing remains in the system as part of the Preventive Maintenance schedule. The Maintenance Dept employees will be in-serviced on proper documentation and testing with this required monthly task.
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 the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of five smoke compartments.

Findings include:

1. Observation on May 12, 2022, at 12:00 pm, revealed the Oxygen Storage Room door failed to close and latch when tested

Interview at the exit conference with the Maintenance Director and the Director of Nursing on May 12, 2022, at 12:30 pm, confirmed the rated door deficiency.



 Plan of Correction - To be completed: 06/20/2022

The closure and latch on the Oxygen Storage Room door was adjusted to ensure proper closure. The Maintenance Director or designee will perform monthly random audits to ensure proper closure and latching of fire rated doors. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.

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