Pennsylvania Department of Health
SARAH REED SENIOR LIVING
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SARAH REED SENIOR LIVING
Inspection Results For:

There are  51 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.
SARAH REED SENIOR LIVING - 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 27, 2024, it was determined that Sarah Reed Senior Living had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


403.748(b)(2), 416.54(b)(1), 418.113(b)(6)(ii) and (v), 441.184(b)(2), 482.15(b)(2), 483.475(b)(2), 483.73(b)(2), 485.542(b)(2), 485.625(b)(2), 485.920(b)(1), 486.360(b)(1), 494.62(b)(1) STANDARD Procedures for Tracking of Staff and Patients:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
403.748(b)(2), 416.54(b)(1), 418.113(b)(6)(ii) and (v), 441.184(b)(2), 460.84(b)(2), 482.15(b)(2), 483.73(b)(2), 483.475(b)(2), 485.542(b)(2), 485.625(b)(2), 485.920(b)(1), 486.360(b)(1), 494.62(b)(1).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at 441.184(b), LTC at 483.73(b), ICF/IIDs at 483.475(b), PACE at 460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at 418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at 485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0018

Based on document review and interview, the facility failed to meet emergency preparedness requirements for one of one emergency preparedness plan.

Findings include:

Document review on March 27, 2024, at 9:44 a.m., revealed the facility failed to provide a staff and resident tracking procedure in case of evacuation to an offsite facility during an emergency.

Interview with the maintenance supervisor on March 27, 2024, at 9:44 a.m., confirmed the facility failed to provide the documentation at the time of the survey.




 Plan of Correction - To be completed: 05/14/2024

1) Current Policy and Procedure for tracking of staff and residents has been located and reviewed. Policy to be placed in Emergency Preparedness binder for future surveys.

2) Policy and Procedure to be reviewed annually and initialed/dated indicating that it was reviewed.

3) This will be monitored and reported at the next QAPI meeting 1x annually.

483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with Patients:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.73(c)(8); 483.475(c)(8)

*[For LTC Facilities at 483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at 483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, the facility failed to meet emergency preparedness requirements for one of one emergency preparedness plan.

Findings include:

Document review on March 27, 2024, at 9:44 a.m., revealed the facility failed to provide an emergency plan sharing procedure for resident families.

Interview with the maintenance supervisor on March 27, 2024, at 9:59 a.m., confirmed the facility failed to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 05/14/2024

1) Share plan for facility Emergency Preparedness posted at main entrance of facility. Share plan to be placed in Emergency Preparedness binder for future surveys.

2) Share plan to include the location of Emergency Preparedness Plans and availability upon request at the main front entrance.

3) This will be monitored and reported at the next QAPI meeting 1x annually.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #710402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 27, 2024, it was determined that Sarah Reed Senior Living 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 three-story, Type II (111), protected, non-combustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to meet fire alarm system testing and maintenance requirements for 20 of over one hundred fire alarm system components.

Findings include:

Document review on March 27, 2024, at 12:00 p.m., revealed the fire alarm system inspection, conducted March 7, 2024, revealed the following system deficiencies:
A. (12:00 p.m.) 18 duct detectors were damaged/worn;
B. (12:00 p.m.) One smoke detector was damaged/worn;
C. (12:00 p.m.) One tamper switch was not connected.

Interview with the maintenance supervisor on March 28, 2024, at 12:00 p.m., confirmed the deficiencies at the time of the survey.




 Plan of Correction - To be completed: 05/12/2024

1) All cited deficiencies were fixed on April 2nd, 2024, by Wilkins. Documentation received.

2) Future deficiencies from fire alarm inspections to be fixed in a timely manner.

3) This will be monitored and reported at the next quarterly QAPI meeting by the Maintenance Supervisor.

NFPA 101 STANDARD Portable Fire Extinguishers:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, the facility failed to maintain portable fire extinguishers in one of two rooms.

Findings include:

Observation on March 27, 2024, at 9:51 a.m., revealed the Type K portable fire extinguisher was not conspicuously located and readily accessible. The extinguisher was located behind the door of the storage room.

Ref: NFPA 10 (2010) 6.1.3.1

Interview with the administrator on March 27, 2024, at 9:51 a.m., confirmed the extinguisher was not readily accessible.






 Plan of Correction - To be completed: 05/12/2024

1) The identified Type K portable fire extinguisher has been moved into the kitchen area and unblocked by door to be more conspicuous.

2) All Type K fire extinguishers in the facility will be evaluated for location in facility and documented that they will be located in conspicuous locations, if not.

3) This will be monitored and reported at the quarterly QAPI/Safety meeting by the Maintenance Supervisor for the next quarter.

NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in one of over six smoke compartments.

Findings include:

Observation on March 27, 2024, at 10:38 a.m., revealed the basement generator room ceiling had an open junction box with exposed wires.

Reference: NFPA 70-314.28(C)

Interview with the maintenance supervisor on March 27, 2024, at 10:38 a.m., confirmed the electrical system deficiency.




 Plan of Correction - To be completed: 05/12/2024

1) Junction box was covered on the day of discovery on 03/27/2024. Maintenance staff to be educated on the importance of secured junction boxes.

2) Junction boxes will be monitored and reported at the next quarterly QAPI meeting by the Maintenance Supervisor for the next quarter.

NFPA 101 STANDARD Electrical Systems - Receptacles:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles in two of more than thirty rooms.

Findings include:

Observation on March 27, 2024, between 9:35 a.m. and 9:58 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations:
A. (9:35 a.m.) Pines Unit clean utility room;
B. (9:58 a.m.) Maples Unit clean utility room.

Interview with the administrator on March 27, 2024, at 9:58 a.m., confirmed the above electrical outlet deficiencies.






 Plan of Correction - To be completed: 05/12/2024

1) Both identified outlets in two clean utility rooms have been replaced with GFCI's on March 28th, 2024.

2) All other clean utility rooms will be audited to ensure no other outlets need to be changed to GFCI's, if within 6 feet of a sink.

3) Outlets will be monitored and reported at the next quarterly QAPI meeting/Safety meeting by the maintenance supervisor.

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, the facility failed to meet essential electrical system requirements for one of one emergency generator.

Findings include:

Document review on March 27, 2024, at 10:20 a.m., revealed the facility provided inconsistent weekly generator reports for battery voltage and visual inspections. One week was provided for January with no year listed, and no documentation was provided for June through December.

Interview with the maintenance supervisor on March 27, 2024, at 10:20 a.m., confirmed the deficiency at the time of the survey.



 Plan of Correction - To be completed: 05/12/2024

1) A new generator documentation form has been developed to include battery voltage and visual inspections with day, month, and year to be signed off on after completion.

2) Maintenance staff to be educated on the new form and documentation process to ensure consistency and accuracy.

3) This will be monitored and reported at the next quarterly QAPI meeting by the Maintenance Supervisor.

Initial comments:Name: NEW ADDITION - Component: 02 - Tag: 0000


Facility ID #710402
Component 02
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on March 27, 2024, it was determined that Sara Reed Senior Living 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 three-story, Type II (111), protected, non-combustible building, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: NEW ADDITION - Component: 02 - Tag: 0345

Based on document review and interview, the facility failed to meet fire alarm system testing and maintenance requirements for 20 of over one hundred fire alarm system components.

Findings include:

Document review on March 27, 2024, at 12:00 p.m., revealed the fire alarm system inspection, conducted March 7, 2024, revealed the following system deficiencies:
A. (12:00 p.m.) 18 duct detectors were damaged/worn;
B. (12:00 p.m.) One smoke detector was damaged/worn;
C. (12:00 p.m.) One tamper switch was not connected.

Interview with the maintenance supervisor on March 27, 2024, at 12:00 p.m., confirmed the deficiencies at the time of the survey.



 Plan of Correction - To be completed: 05/12/2024

1) All cited deficiencies were fixed on April 2nd, 2024, by Wilkins. Documentation received.

2) Future deficiencies from fire alarm inspections to be fixed in a timely manner.

3) This will be monitored and reported at the next quarterly QAPI meeting by the Maintenance Supervisor.

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: NEW ADDITION - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to meet essential electrical system requirements for one of one emergency generator.

Findings include:

Document review on March 27, 2024, at 10:20 a.m., revealed the facility provided inconsistent weekly generator reports for battery voltage and visual inspections. One week was provided for January with no year listed, and no documentation was provided for June through December.

Interview with the maintenance supervisor on March 27, 2024, at 10:20 a.m., confirmed the deficiency existed at the time of the survey.




 Plan of Correction - To be completed: 05/12/2024

1) A new generator documentation form has been developed to include battery voltage and visual inspections with day, month, and year to be signed off on after completion.

2) Maintenance staff to be educated on the new form and documentation process to ensure consistency and accuracy.

3) This will be monitored and reported at the next quarterly QAPI meeting by the Maintenance Supervisor.


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