Nursing Investigation Results -

Pennsylvania Department of Health
ROSEWOOD REHABILITATION AND NURSING CENTER
Building Inspection Results

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ROSEWOOD REHABILITATION AND NURSING CENTER
Inspection Results For:

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ROSEWOOD REHABILITATION AND NURSING 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 September 3, 2019, at Rosewood Rehabilitation and Nursing 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 #701002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 3, 2019, it was determined that Rosewood Rehabilitation and Nursing 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 four-story, Type II (222), fire resistive 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 sprinkler head assemblies to be complete, and to be free of obstruction, affecting two of four floors within the component.

Findings include:

1. Observation on September 3, 2019, at 11:43 AM revealed two sprinkler heads, located within the 1st floor Computer Room, each lacked an escutcheon.

Interview with the Maintenance Director on September 3, 2019, at 11:43 AM confirmed the missing escutcheons.


2. Observation on September 3, 2019, at 11:55 AM revealed a bird nest constructed atop the sidewall sprinkler head, located in the exterior vestibule of the 2nd floor Exit Stairtower, facing the front of the building.

Interview with the Maintenance Director on September 3, 2019, at 11:55 AM confirmed the obstructed sprinkler head.



 Plan of Correction - To be completed: 10/15/2019

1. The bird's nest was removed from the side wall sprinkler head located in the 2nd Floor Exit Stairtower. The missing escutcheons located within the 1st Floor Computer Room were replaced.

2. The date the corrective action was completed was 10/15/2019.

3. The maintenance staff were in-serviced as to the importance of maintaining the sprinkler head assemblies.

4. The Administrator/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.

NFPA 101 STANDARD Corridor - 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.
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 corridor doors to be free of obstruction to closing, affecting one of four floors within the component.

Findings include:

1. Observation on September 3, 2019, at 12:08 PM revealed the door to the 2nd floor Clean Linen Room was obstructed from closing by a linen cart.

Interview with the Maintenance Director on September 3, 2019, at 12:08 PM confirmed the door was obstructed from closing.



 Plan of Correction - To be completed: 10/15/2019

1. The clean-linen cart was removed from the 2nd Floor Clean Linen Room.

2. The date the corrective action was completed was 10/15/2019.

3. 2nd Floor Staff will be in-serviced as to the importance of keeping doors unobstructed.

4. The Housekeeping Director/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further 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 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, affecting one of four floors within the component.

Findings include:

1. Observation on September 3, 2019, at 12:35 PM revealed penetrations of the smoke barrier wall, around two black HVAC lines. and around two silver conduits, located above the double doors, next to Resident Room 318, in the 3B Wing.

Interview with the Maintenance Director on September 3, 2019, at 12:35 PM confirmed there were penetrations.


2. Observation on September 3, 2019, at 12:42 PM revealed penetrations of the smoke barrier wall, around two black HVAC lines, and around a cluster of white wires located above the double doors, by Resident Room 329, in the 3B Wing.

Interview with the Maintenance Director on September 3, 2019, at 12:42 PM confirmed there were penetrations.





 Plan of Correction - To be completed: 10/15/2019

1. The smoke barrier penetrations around the black HVAC lines and silver conduits above the double doors in proximity of Resident Room 318 penetrations will be sealed using a UL approved fire stop penetrations system.

2. The date the corrective action was completed was 10/15/2019.

3. Maintenance staff will be in-serviced on the importance of identifying and correcting smoke barrier penetrations.

4. The Maintenance Director/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of electrical devices, affecting two of four floors within the component.

Findings include:

1. Observation on September 3, 2019, at 11:40 AM revealed three daisy-chained surge protectors supplying power to computer equipment, within the 1st floor Computer Room.

Interview with the Maintenance Director on September 3, 2019, at 11:40 AM confirmed the unauthorized use of surge protectors.


2. Observation on September 3, 2019, at 12:05 PM revealed a surge protector supplying power to a microwave, within the 2nd floor Kitchenette.

Interview with the Maintenance Director on September 3, 2019, at 12:05 PM confirmed the unauthorized use of a surge protector.




 Plan of Correction - To be completed: 10/15/2019

1. The surge protectors in the 1st floor computer room were uncoupled, and the surge protector was removed from the 2nd floor kitchenette.

2. The date the corrective action was completed was 10/15/2019.

3. Maintenance staff will be in-serviced on the importance of monitoring the use of electrical devices.

4. The Maintenance Director/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.

Initial comments:Name: EXISTING KITCHEN AND DINING AREA - Component: 02 - Tag: 0000


Facility ID #701002
Component 02
Existing Kitchen and Dining Area

Based on a Medicare/Medicaid Recertification Survey completed on September 3, 2019, it was determined that Rosewood Rehabilitation and Nursing 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 II (000), unprotected noncombustible 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: EXISTING KITCHEN AND DINING AREA - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler heads to be active, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on September 3, 2019, at 11:05 AM revealed an inoperative sprinkler head (remnant of a decommissioned system) installed within the suspended ceiling of the Storage Room, located within the Inside Loading Dock.

Interview with the Maintenance Director on September 3, 2019, at 11:05 AM confirmed the presence of an inoperative sprinkler head.



 Plan of Correction - To be completed: 10/15/2019

1. The inoperative sprinkler components installed in the suspended ceiling of the storage room inside the loading dock area were removed from above the ceiling

2. The date the corrective action was completed was 10/15/2019.

3. Maintenance staff will be in-serviced on the importance of maintaining inoperative sprinkler components.

4. The Maintenance Director/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.

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: EXISTING KITCHEN AND DINING AREA - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguisher signage, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on September 3, 2019, at 10:57 AM revealed the fire extinguisher indicator bulb, located within the Inside Loading Dock, was not illuminated.

Interview with the Maintenance Director on September 3, 2019, at 10:57 AM confirmed the indicator bulb was not illuminated.




 Plan of Correction - To be completed: 10/15/2019

1. The fire extinguisher indicator bulb inside the loading dock was repaired and is in working order.

2. The date the corrective action was completed was 10/15/2019.

3. Maintenance staff will be in-serviced on the importance of maintaining the fire extinguisher indicator bulb inside the loading dock.

4. The Maintenance Director/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: EXISTING KITCHEN AND DINING AREA - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, affecting two of two smoke compartments within the component.

Findings include:

1. Observation on September 3, 2019, at 10:47 AM revealed penetrations of the smoke barrier wall around four lighting control conduits, and two fire alarm wires, within the Activities Storage Room.

Interview with the Maintenance Director on September 3, 2019, at 10:47 AM confirmed there were penetrations.



 Plan of Correction - To be completed: 10/15/2019

1. The smoke barrier penetrations around the four lighting control conduits and two fire alarm wires in proximity of the Activities Storage Room were sealed using an approved stop gap penetration system.

2. The date the corrective action was completed was 10/15/2019.

3. Maintenance staff will be in-serviced on the importance of identifying and correcting smoke barrier penetrations.

4. The Maintenance Director/Designee will conduct random monthly compliance rounds. Results of the audits will be presented at the monthly Quality Assurance and Performance Improvement Meeting for further review and/or recommendations.


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