Pennsylvania Department of Health
QUALITY LIFE SERVICES - NEW CASTLE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 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.


QUALITY LIFE SERVICES - NEW CASTLE - 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 5, 2024, at Quality Life Services-New Castle, 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 #850302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 5, 2024, it was determined that Quality Life Services-New Castle 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 V (000), unprotected, wood building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain accurate, portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on June 5, 2024, at 10:44 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site to be used during the Life Safety Code Survey.

The Life Safety Code floor plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall and enclosures)
b. Fire barrier walls (indicating 1-2 hour walls)
c. Horizontal exits
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan
e. Required exits should be clearly noted
f. Shaft walls

Interview at the exit conference with the maintenance supervisor on June 5, 2024, at 10:44 a.m., confirmed the facility's Life Safety Code Floor Plan failed to accurately identify stairwell enclosures.

Plan of Correction - To be completed: 07/28/2024

Stairwell enclosures were color coded on the facility floorplan to meet Life Safety Code Floor Plan on 6/5/24.

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, document review, and interview, the facility failed to maintain exit and exit discharge requirements for three of over eight exits.

Findings include:

1. Observation on June 5, 2024, between 9:01 a.m. and 10:44 a.m. , revealed the following deficiencies:
A. (9:01 a.m.) Basement 1 west exit pathway door had hardware installed to lock. When tested, the door remained locked;
B. (10:44 a.m.) First floor 2 west dining room had exit signage pointing towards the dining room door. The door did not have an exit discharge pathway that was level and hard-packed and that led to a public way. The pathway had a drop-off that lead to grass, possibly slowing the evacuation process during an emergency.

Interview with the maintenance supervisor on June 5, 2024, at 10:25 a.m., confirmed the deficiency at the time of the survey.

2. Document review on June 5, 2024, 11:10 a.m., revealed the facility was unable to provide documentation for the courtyard exit door that has a key lock. The facility had no evacuation procedure for this door in the event of an emergency.

Interview with the maintenance supervisor on June 5, 2024, at 11:10 a.m., confirmed the deficiency at the time of the survey.

3. Interview on June 5, 2024, 10:44 a.m., which included one activities staff member and three therapy staff members, revealed the employees were unaware of how to unlock and evacuate residents through the courtyard door. One therapy staff member was aware that there was a key for the door, but was unsure of its location. The staff members were informed that all department heads have a key to unlock all keyed doors.

Interview with the maintenance supervisor on June 5, 2024, at 10:44 a.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 07/28/2024

1. A. Hardware was immediately removed from the door located in Basement 1 west exit pathway.
1. B. Signage was placed on the door stating "This is not an emergency exit." The exit sign points to the hall area that has an emergency exit to the right and the exit in question is located on the left. It would not be considered a defined egress for emergency. The floor plan does not indicate the exit in question as an emergency exit.

2.Evacuation procedure for the courtyard locked gate has been written and staff education has been completed. Key for the lock is located in the nursing office on the Supervisor key chain and each Department Head has been provided with a key.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, the facility failed to meet stairway enclosure requirements for one of over two stairway enclosures.

Findings include:

Observation on June 5, 2024, at 10:01 a.m., revealed the stairway enclosure leading to the boiler room, near the lobby, lacked latching hardware. A magnetic release was installed on the door that would release in the event of a fire, allowing smoke passage.

Interview with the maintenance supervisor and administrator on June 5, 2024, at 10:01 a.m., confirmed the door did not have latching hardware.

Plan of Correction - To be completed: 07/28/2024

Maintenance Director spoke with Hardware Specialty and they will be in the facility on 6/12/24 to provide estimate and plan for installation of latching hardware to be installed by date certain. Maintenance Director has completed a walk through to ensure all other stairwell doors have latching hardware and has been educated to ensure no additional issues in the future.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit and directional signage at one of over four emergency exits.

Findings include:

Observation on June 5, 2024, at 10:25 a.m., revealed the first floor hall between the kitchen and south dining room did not have a directional exit sign, which could possibly cause confusion during an emergency.

Interview with the maintenance supervisor on June 5, 2024, at 10:25 a.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 07/28/2024

A directional exit sign was installed by the Maintenance Director on 6/6/2024. Maintenance Director has completed a walk through and has found exit areas to be clearly marked. Maintenace Director was educated to the need to ensure all exit areas are well marked to avoid confusion during an emergency situation.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement