Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LUZERNE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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KADIMA REHABILITATION & NURSING AT LUZERNE - 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 February 21, 2024, at Kadima Rehab and Nursing at Luzerne, 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# 283802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that Kadima Rehabilitation and Nursing at Luzerne, 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 frame building, with basement, that 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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain three hazardous area enclosures, affecting one of three smoke compartments.

Findings include:

1. Observation on February 21, 2024, between 10:55 a.m., and 11:03 a.m., revealed the following hazardous area enclosure deficiencies at the basement level:

a. 10:55 a.m., The Chemical Room door was held open by unapproved means.
b. 11:00 a.m., The Overflow Storage Room door lacked a self-closing device.
c. 11:03 a.m., The Laundry Room door was held open by unapproved means.

Exit interview with the Facility Administrator and the Facilities Manager on February 21, 2024, between 11:45 a.m., and 12:00 p.m., confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 02/28/2024

1. The Maintenance Director and NHA posted signs that state doors must always remain closed on each door.
2. The Maintenance Director installed self-closing device on the Overflow Storage Room.
3. The Maintenance Director educated all staff on the importance of keeping these specific doors closed and not have anything obstructing the closure of these doors.
4. During daily routine rounding, the Maintenance Director and NHA will check to make sure doors are properly closed and there are no obstructions to the closure.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 two of three smoke compartments.

Findings include:

1. Observation on February 21, 2024, between 10:55 a.m. and 11:23 a.m., revealed the following:

a. 10:55 a.m., Penetrations of the basement-level, Chemical Room ceiling.
b. 11:20 a.m., insulating materials atop a sprinkler head assembly, located within the attic space.
c. 11:23 a.m., wiring affixed to branch sprinkler piping, located within the attic space.

Exit interview with the Facility Administrator and the Facilities Manager on February 21, 2024, between 11:45 a.m., and 12:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 03/01/2024

1. The Maintenance Director cut drywall to replace the damaged areas of the Chemical Room ceiling and filled gaps with spackle and silicone.
2. The Maintenance Director immediately removed the insulation that was covering the sprinkler head and stapled it back to prevent it from covering the sprinkler head in the future.
3. The Maintenance Director immediately removed wiring that was wrapped around branch sprinkler piping and anchored it with a zip tie to prevent it from being wrapped around the pipe.
4. NHA and the Maintenance Director have implemented a checklist to complete after each contracted service exits the attic area.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of three smoke compartments.

Findings include:

1. Observation on February 21, 2024, at 11:17 a.m., revealed the first floor, Resident Room 2 door was not smoke-tight.

Exit interview with the Facility Administrator and the Facilities Manager on February 21, 2024, between 11:45 a.m., and 12:00 p.m., confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 03/01/2024

1. NHA and the Maintenace Director performed a one time audit of facility to check if there were gaps in any other resident rooms. None were found.
2. The Maintenance Director repositioned door latch, and door was able to be sealed tightly.
3. NHA and the Maintenance Director will add to the positive latch audit to also check gaps in the seal of door.
4. The Maintenance Director will fix any gaps in door seal immediately after identifying them during the audit.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting two of three smoke compartments.

Findings include:

1. Observation on February 21, 2024, at 11:29 a.m., revealed the attic level, smoke barrier separation door was open, and the spring tensioning device had been disabled.

Exit interview with the Facility Administrator and the Facilities Manager on February 21, 2024, between 11:45 a.m., and 12:00 p.m., confirmed the smoke barrier door deficiency.

Plan of Correction - To be completed: 03/01/2024

1. Spring tension device was immediately placed into proper working position.
2. NHA and the Maintenance Director performed a one time facility wide audit to ensure that there were no other doors with spring tension devices. None were found.
3. The Maintenance Director placed a sign near attic door that states not to remove spring tension mechanism.
4. NHA and the Maintenance Director have implemented a checklist to complete after each contracted service exits the attic area.

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to maintain fire drills in three of twelve instances, affecting two of two floor.

Findings include:

1. Observation on February 21, 2024, at 11:44 a.m., revealed the facility lacked fire drills for the first quarter of the previous twelve month period (first, second and third shifts).

Exit interview with the Facility Administrator and the Facilities Manager on February 21, 2024, between 11:45 a.m., and 12:00 p.m., confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 03/01/2024

1. NHA and Maintenance Director could not retroactively complete missed required annual fire drills.
2. NHA and the Director of Maintenance were re-educated on the importance of completing scheduled annual fire drills.
3. NHA and the Maintenance Director created a new schedule for fire drills to ensure they happen monthly on each shift (12 per year).
4. NHA will perform monthly audits to ensure one fire drill was performed that month.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain the electrical systems in one location, affecting one of three smoke compartments.

Findings include:

1. Observation on February 21, 2024, at 11:25 a.m., revealed a junction box, located within the attic space, lacked a cover plate.

Exit interview with the Facility Administrator and the Facilities Manager on February 21, 2024, between 11:45 a.m., and 12:00 p.m., confirmed the electrical deficiency.

Plan of Correction - To be completed: 03/01/2024

1. NHA and the Maintenance Director performed a one-time facility wide audit of other junction boxes to ensure they were covered properly. All were covered.
2. The Maintenance Director covered the junction box located in attic space with proper metal covering.
3. The Maintenance Director will ensure all junction boxes are covered in the future during daily rounding.

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