Pennsylvania Department of Health
DUNMORE HEALTH CARE CENTER
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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
DUNMORE HEALTH CARE CENTER
Inspection Results For:

There are  37 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.
DUNMORE HEALTH CARE 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 January 30, 2024, at Dunmore Health Care 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: 02 - Tag: 0000


Facility ID# 120902
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2024, it was determined that Dunmore Health Care 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 483.70(a).

This is a two story, Type II (111), protected noncombustible building, that is fully sprinklered



 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain fire rated construction, affecting one of six smoke compartments.

Findings include:

1. Observation on January 30, 2024, at 10:35 a.m., revealed fire alarm and metallic cable penetrations of the fire rated ceiling on the 2nd floor, near the elevator.

Interview at the time of the exit conference with the administrator and maintenance supervisor on January 30, 2024, at 12:30 pm, confirmed the open wiring penetrations.







 Plan of Correction - To be completed: 02/23/2024

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
- The penetration in the ceiling of the 2nd Floor Mechanical Room was repaired.

- A review of the facility will be completed to check for building construction issues and repair if needed.

- Maintenance Director will be educated on the proper building construction requirements.

- Facility will be randomly audited monthly x3 to ensure proper building construction. Trends will be reviewed at QAPI meeting monthly.
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: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one of six smoke compartments.

Findings include:

1. Observation on January 30, 2024, at 12:00 pm, revealed the door to room 103 was not smoke tight when latched in the frame.

Interview at the time of the exit conference with the administrator and maintenance supervisor on January 30, 2024, at 12:30 pm, confirmed the lacked smoke tight integrity.





 Plan of Correction - To be completed: 02/23/2024

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
- The door to room 103 was repaired to be smoke tight.

- The smoke doors throughout the facility that open to the corridor were checked for smoke tightness.

- Maintenance Director will be educated on the need for doors leading to corridors to be smoke tight.

- corridor facing doors will be randomly audited monthly x3 to ensure the doors are smoke tight. Trends will be reviewed at QAPI meeting monthly.

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

Visit the PA Power Port