Pennsylvania Department of Health
NIGHTINGALE NURSING AND REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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NIGHTINGALE NURSING AND REHAB 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 March 5, 2024, at Nightingale Nursing and Rehabilitation 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 01 - Component: 01 - Tag: 0000

Facility ID #191302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 5, 2024, it was determined that Nightingale Nursing and Rehab 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 three-story, Type II (111), protected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

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 observation, document review, and interview, the facility failed to maintain the fire alarm system, affecting one of over five zones.
Findings include:
Document review on March 5, 2024, at 10:09 a.m., revealed the fire alarm panel had a trouble signal for an air handler relay.

Interview with the maintenance supervisor on March 5, 2024, at 10:09 a.m., confirmed the fire alarm panel displayed a trouble signal and had Swartz Fire address the issue on-site.

Plan of Correction - To be completed: 04/01/2024

The Maintenance Director immediately contacted Schwartz Fire Alarm Services to troubleshoot the air handler relay trouble light. Schwartz Fire Alarm Services confirmed all other functions fully operational and recommended that the Maintenance Director contact Johnson Controls for repair. Repairs scheduled for 3/14/2024. Audit to be conducted 3 days per week for 2 weeks then 1 time per week for 2 weeks, then monthly for 2 months by the Maintenance Director or designee to ensure no additional trouble lights are on. Results will be reviewed at QAPI, and the committee will determine if further action is required.

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 maintain the essential electric system for one of one diesel-powered emergency generator.

Findings include:

Document review on March 5, 2024, at 11:00 a.m., revealed the facility failed to provide documentation for the following tests:
A. Monthly specific gravity or conductance;
B. Three-year, four-hour load;
C. Annual fuel analysis report.

Interview with the maintenance supervisor on March 5, 2024, at 11:00 a.m., confirmed the tests were not completed.

Plan of Correction - To be completed: 04/01/2024

The Maintenance Director scheduled Cleveland Brothers for generator service on 3/19/2024-3/21/2024. During that service time, the fuel sample for the annual fuel analysis will be obtained and the four-hour load test will be conducted. The preventative maintenance schedule has been updated to include both tests. The monthly preventative maintenance schedule has been updated to include conductance testing on the maintenance-free batteries. Additionally, an audit will be completed by the Administrator or designee monthly for three months to ensure the monthly conductance testing is completed. Results will be reviewed at QAPI, and the committee will determine if further action is required.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #191302
Component 02
Gallagher Building

Based on a Medicare/Medicaid Recertification Survey completed on March 5, 2024 it was determined that Nightingale Nursing and Rehabilitation Center was not in compliance with the 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, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain the essential electric system for one of one natural gas-powered emergency generator.

Findings include:

Document review on March 5, 2024, at 11:00 a.m., revealed the facility failed to provide documentation for the following tests:
A. Monthly specific gravity or conductance;
B. Three-year, four-hour load.

Interview with the maintenance supervisor on March 5, 2024, at 11:00 a.m., confirmed the tests were not completed.

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