Pennsylvania Department of Health
GREENWOOD CENTER FOR REHABILITATION AND NURSING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GREENWOOD CENTER FOR REHABILITATION AND NURSING - 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 14, 2024, at Greenwood Center for Rehabilitation and Nursing, 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 #151202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 14, 2024, it was determined that Greenwood Center for Rehabilitation and Nursing 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, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting two of five smoke compartments within the component.

Findings include:

1. Observation on March 14, 2024, at 1:50 PM, revealed three unprotected penetrations of the Soiled Utility Room, by Resident Room 204, around three water pipes.

Interview with the Administrator and the Maintenance Coordinator on March 14, 2024, at 1:50 PM, confirmed the unprotected penetrations of the hazardous area wall.

2. Observation on March 14, 2024, at 2:25 PM, revealed three unprotected penetrations of the Soiled Utility Room, across from Room 407, around three water pipes.

Interview with the Administrator and the Maintenance Coordinator on March 14, 2024, at 2:25 PM, confirmed the unprotected penetrations of the hazardous area wall.

Plan of Correction - To be completed: 03/26/2024

1. The unprotected penetrations of the Soiled Utility Room wall in the 200 and 400 halls were repaired using an approved through penetration fire stop system. The facility will maintain the rating of the hazardous areas.

2. The soiled utility rooms in 100, 300 and 500 halls were audited for any unprotected penetration. Audits will be conducted quarterly throughout the year for penetrations.

3. The Maintenance staff were educated by the Maintenance Director regarding unprotected penetration of walls and the need for repair on 3/15/24.

4. Audits will be reviewed quarterly at QAPI.

NFPA 101 STANDARD Corridor - Doors:

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 the positive latching of corridor doors, affecting one of five smoke compartments within the component.

Findings include:

1. Observation on March 14, 2024, at 1:55 PM, revealed the door to the 100 Hall Store Room failed to positively latch within the door frame.

Interview with the Administrator and the Maintenance Coordinator on March 14, 2024, at 1:55 PM, confirmed the door did not latch within the frame.

Plan of Correction - To be completed: 03/26/2024

1. The 100 Hall Storeroom door was repaired to latch fully within the door frame by the Milroy Door Company.

2. The remaining storeroom doors in the facility were audited to ensure the doors fully latched. Audits for corridor doors will be done monthly throughout the year. A one time, facility wide, corridor door audit will be done with random doors checked monthly throughout the facility.

3. Maintenance staff were educated by the Maintenance Director regarding doors fully latching on 3/15/24.

4. Audits will be reviewed at quarterly at QAPI.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 smoke resistance of smoke barrier walls, affecting two of five smoke compartments within the component.

Findings include:

1. Observation on March 14, 2024, at 2:06 PM, revealed two unprotected penetrations of the smoke barrier wall, within the Activities Suite, around two green electrical cables and one silver conduit, above the access panel closest to the corridor wall.

Interview with the Administrator and the Maintenance Coordinator on March 14, 2024, at 2:06 PM, confirmed the unprotected penetrations of the smoke barrier wall.

Plan of Correction - To be completed: 03/26/2024

1. The two unprotected penetrations of the smoke barrier wall, within the Activities Suite, around two green electrical cables and one silver conduit, above the access panel closest to the corridor wall were repaired using an approved through penetration fire stop system.

2. No other unprotected penetrations of smoke barrier walls were identified. The facility will maintain the rating of the smoke barrier walls.

3. The maintenance staff were educated by the Maintenance Director regarding the sealing/protecting of penetrations of smoke barrier walls on 3/15/14.

4. Audits will be conducted throughout the year, quarterly, throughout the facility.

5. Audits will be reviewed quarterly at QAPI.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain the physical integrity of electrical receptacles, affecting one of five smoke compartments within the component.

Findings include:

1. Observation on March 14, 2024, at 2:35 PM, revealed the corridor electrical receptacle, next to Resident Room 503, was physically broken.

Interview with the Administrator and the Maintenance Coordinator on March 14, 2024, at 2:35 PM, confirmed the broken electrical receptacle.

Plan of Correction - To be completed: 03/26/2024

1. The corridor receptacle, next to Resident room 503 was replaced and tested.

2. Audits of the remaining outlets in the facility were conducted to ensure the outlets were intact and free of damage. Audits for physical integrity of electrical outlets will be conducted at least semi-annually throughout the facility.

3. The maintenance staff were educated by the Maintenance Director regarding ensuring outlets are free from damage on 3/15/14.

4. Audits will be reviewed semi-annually at QAPI.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 extension cords and receptacle multipliers, affecting one of five smoke compartments within the component.

Findings include:

1. Observation on March 14, 2024, at 2:44 PM, revealed a receptacle multiplier supplying electrical power to an extension cord, within the Social Services Office.

Interview with the Administrator on March 14, 2024, at 2:44 PM, confirmed the use of a receptacle multiplier.

Plan of Correction - To be completed: 03/26/2024

1. The receptacle multiplier supplying electrical power to an extension cord, within the Social Services Office was removed.

2. Audits of remaining offices were conducted to identify extension cord use with receptacle multipliers. All unauthorized electrical devices have been removed, and a onetime facility sweep has been performed to identify and remove any other electrical multipliers/extension cords.

3. Maintenance staff were educated by the Maintenance Director on the use of extension cords and receptacle multipliers on 3/15/24.

4. Audits will be reported at QAPI quarterly.

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