Pennsylvania Department of Health
 WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER
Building Inspection Results

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WECARE AT SYCAMORE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  44 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.
WECARE AT SYCAMORE REHABILITATION AND NURSING 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 28, 2024, at Wecare at Sycamore Rehabilitation and Nursing 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# 194402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 28, 2024, it was determined that Wecare at Sycamore Rehabilitation and Nursing 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 483.90(a).

This is a one story, Type III (200), unprotected, ordinary building, with a partial basement, a basement-level crawl space, and an unused attic, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of two floors.

Findings include:

1. Observation on March 28, 2024, at 9:55 a.m., revealed wiring located atop branch sprinkler piping, located within the basement-level, exit access corridor, closest to the elevator enclosure.

Interview at the time of the exit conference with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the automatic sprinkler system deficiency.



 Plan of Correction - To be completed: 05/07/2024

1.The wiring has been removed from the branch sprinkler pipe on 3/29/24.
2.Education will be provided by the NHA/Designee to the Maintenance team on sprinkler pipes and wiring.
3.Audits will be conducted weekly x 3 months by the Maintenance Director/designee. Results will be report to QAPI.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in one location, affecting one of one floors within the component.

Findings include:

1. Observation on March 28, 2024, at 10:34 a.m. revealed a hole, located on the nurse's station door of the Little League Blvd wing, above the door hardware.

Exit interview with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the corridor opening deficiencies.









 Plan of Correction - To be completed: 05/07/2024

1.The penetration on the little league nurses station door was sealed with intumescent fire caulk on 4/3/24.
2.Maintenance staff will be educated on penetrations in rated doors by the NHA/Designee.
3.Audits will be conducted weekly x 3 months by the Maintenance Director/designee to ensure no other penetrations are in doors. Results will be reported to QAPI.

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000


Facility ID# 194402
Component 03
Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on March 28, 2024, it was determined that Wecare at Sycamore Rehabilitation and Nursing 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 483.90(a).

This is a one story, Type V (111), protected, wood frame building, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0133

Based on observation and interview it was determined the facility failed to maintain the two hour fire resistance rating of common walls and communicating openings in three locations, affecting one of one floors. within the component.

Findings include:

1.Observation on March 28, 2024, between 10:36 a.m. and 11:34 a.m., revealed the following:

a. At 10:36 a.m., Hallway near Infectious Control, Storage Room, door frame lacked fire rating label.
b. At 10:38 a.m., Hallway near Infectious Control, Oxygen Storage Room, door frame lacked fire rating label.
c. At 11:34 a.m., the common wall within the 01 Component lacked required, two-hour, fire-resistive integrity at the covered window openings (single layer of five-eighth-inch gypsum board on either side of window openings).

Interview at the time of the exit conference with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the common wall and communicating opening deficiencies.




 Plan of Correction - To be completed: 05/07/2024

1.The facility is requesting a 6-month time limited waiver. The facility will seek guidance from an engineer on correct construction of wall and door frames.
2.Maintenance staff will be educated on 2 hour rated walls by the NHA/Designee.
3.An audit will be conducted weekly x 3 months by the Maintenance Director/designee on fire rated walls. Results will be reported to QAPI.

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: BUILDING 03 - Component: 03 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of one floor.

Findings include:

1. Observation on March 28, 2024, at 11:22 a.m., revealed the gypsum board portion of the rated ceiling assembly, located within the exit access corridor, closest to infection control, had been removed.

Interview at the time of the exit conference with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the building construction deficiency.




 Plan of Correction - To be completed: 05/07/2024

1.The facility is requesting a 6-month time limited waiver. The facility will seek guidance from an engineer on monolithic ceilings.
2.The maintenance staff will be educated by the NHA/Designee on 1 hour rated ceiling assemblies.
3.An audit will be conducted weekly x 3 months by the Maintenance Director/designee on fire rated ceiling assemblies. Results will be reported to QAPI.

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: BUILDING 03 - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one location, affecting one of one floor within the component.

Findings include:

1. Observation on March 28, 2024, at 11:00 a.m., revealed the equipment room door inside of therapy, failed to latch when tested.

Interview at the time of the exit conference with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the door failed to latch when closed.















 Plan of Correction - To be completed: 05/07/2024

1.The therapy room door latch was adjusted to ensure proper latching on 4-3-24.
2.The maintenance staff will be educated on proper latching of doors by the NHA/Designee
3.Audits will be conducted weekly x 3 months by the Maintenance Director/designee to ensure proper door latching and will be reported to QAPI monthly.

NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one location, affecting one of two floors.

Findings include:

1. Observation on March 28, 2024, at 10:10 a.m., revealed a penetration of the basement-level portion of the corridor wall system, located closest to Room 611.

Interview at the time of the exit conference with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the corridor wall deficiency.






 Plan of Correction - To be completed: 05/07/2024

1.The penetration in the hallway wall outside room 611 was sealed with intumescent fire caulk on 4/3/24.
2.The maintenance staff will be educated by the NHA/Designee on corridor wall penetrations.
3.Audits will be conducted weekly x 3 months by the Maintenance Director/designee on corridor wall penetrations and reported to QAPI monthly.

NFPA 101 STANDARD Electrical Equipment - Other: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.
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)
Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain the electrical system in one location, affecting one of one floor within the component.

Findings include:
1. Observation on January 22, 2024, 10:44 a.m., revealed a junction box lacked a cover plate, located above the ceiling, within the hallway, closest to infectious control.


Exit interview with the Facility Administrator and the Facilities Manager between 12:15 p.m., and 12:30 p.m., on March 28, 2024, confirmed the electrical systems deficiencies.







 Plan of Correction - To be completed: 05/07/2024

1.The cover was replaced on junction box above ceiling outside infection control room on 4/3/24.
2.The maintenance staff will be educated on proper covering of junction boxes.
3.Audits will be conducted on properly covered junction boxes weekly x 3 months by the Maintenance Director/designee and reported to QAPI monthly.


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