Pennsylvania Department of Health
 LECOM AT PRESQUE ISLE, INC.
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
LECOM AT PRESQUE ISLE, INC.
Inspection Results For:

There are  40 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.
LECOM AT PRESQUE ISLE, INC. - 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 28, 2024, at Lecom at Presque Isle, Inc., 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 #530402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 28, 2024, it was determined that Lecom at Presque Isle, Inc. 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 483.90(a).

This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview, the facility failed to test, clean, and change the batteries for the carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

Document review on February 28, 2024, at 10:00 a.m., revealed the facility lacked documentation that the the carbon monoxide detectors were cleaned and tested, and that the batteries were changed within the previous twelve months.

Interview with the maintenance supervisor on February 28, 2024, at 10:00 a.m., confirmed the facility lacked the documentation.



 Plan of Correction - To be completed: 03/29/2024

K0100 requires that carbon monoxide detectors are to be tested, cleaned, and have batteries changed in accordance to manufacturing recommendations/in the last 12 months. Facility will complete testing and cleaning of carbon monoxide detectors as stated by manufacturers standards.
Facility will complete audit of Carbon Monoxide detectors weekly utilizing a check off sheet. Sheet will list location, that the product was cleaned, batteries are in working order or that they have been replaced.
Audit will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Building Construction Type and Height: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.
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 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to inspect and maintain the ceiling tiles, in one of five wings.

Findings include:

Observation on February 28, 2024, at 1:00 p.m., revealed the laundry wing boiler room was missing a ceiling tile, allowing the passage of smoke.

Interview with the maintenance supervisor on February 28, 2024, at 1:00 p.m., confirmed the deficiency.




 Plan of Correction - To be completed: 03/29/2024

Facility was found to be missing a tile from the ceiling in the laundry wing boiler room. This allows smoke to leave this location of the facility with little to no barrier.
Facility has replaced the missing ceiling tile in the laundry wing boiler room.
Facility has completed a walking audit of all locations of the facility to find other missing ceiling tiles. None were reported.
Audit will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to provide documentation for functional tests of the battery-powered emergency lighting throughout the entire facility.

Findings include:

Document review on February 28, 2024, at 10:45 a.m., revealed the facility lacked documentation for monthly 30-second testing and annual 90-minute testing.

Interview with the maintenance supervisor on February 28, 2024, at 10:45 a.m., confirmed the facility could not provide documentation that the emergency lighting tests were completed.




 Plan of Correction - To be completed: 03/29/2024

Facility will complete monthly 30 second and annual 90 minute testing of all battery operated emergency lighting.
Audit slip will include location, date tested, time tested start to finish, and results.
Audit will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 document review and interview, the facility failed to maintain fire alarm system components, affecting the entire facility.

Findings include:

Document review on February 28, 2024, at 10:30 a.m., revealed the facility could not provide documentation for the following testings/inspections that were to have occurred within the previous twelve months:
A) (Annual) functional fire alarm;
B) (Semi-annual) visual fire alarm.

Interview with the maintenance supervisor on February 28, 2024, at 10:30 a.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 03/29/2024

Facility Failed to provide the necessary documentation for semi annual and annual documentation for fire alarm testing.
Fire alarm testing documentation will be completed for semi annual and annual fire alarm testing.
Facility has made contact with contractor to complete semiannual and annual testing.
Audit will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on document review and interview, the facility failed to maintain smoke detectors for all battery-operated smoke detectors throughout the facility.

Findings include:

Document review on February 28, 2024, at 9:45 a.m., revealed the facility failed to provide the following documentation for battery-operated smoke detectors:
A) Monthly testing and cleaning;
B) Six-month battery replacement and/or ten-year device replacement for ten-year sealed units.

Interview with the maintenance director on February 28, 2024, at 9:45 a.m., confirmed the battery-operated smoke detector testing shall occur weekly.





 Plan of Correction - To be completed: 03/29/2024

Facility failed to provide documentation for proof of smoke detector testing, cleaning. Facility failed to do 6 month battery replacement and/or replacement of sealed units.
Facility will complete weekly testing of battery operated smoke detectors as directed by the current utilized smoke detectors throughout facility.
Facility will utilized audit sheet indicating date of inspection, location, cleaning completed, and if battery was replaced. This will be completed weekly/as directed by smoke detector manufacturer instruction.
Completion will be reviewed at monthly QAPI

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review and interview, the facility failed to maintain portable fire extinguishers for three of twelve months.

Findings include:

Document review on February 28, 2024, at 11:46 a.m., revealed the facility lacked documentation that the portable fire extinguishers were inspected during August-October 2023.

Interview with the maintenance supervisor on February 28, 2024, at 11:46 a.m., confirmed the portable fire extinguisher documentation was unavailable at the time of the survey.




 Plan of Correction - To be completed: 03/29/2024

Facility failed to complete fire extinguisher documentation for 3 of the 12 months.
Facility will complete monthly inspections of all fire extinguishers. Environmental Services Manager will review completion of audit with administrator monthly at QAPI.

NFPA 101 STANDARD Fire Drills: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.
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 document review and interview, the facility failed to perform three of twelve required fire drills.

Findings include:

Document review on February 28, 2024, at 9:30 a.m., revealed the facility lacked documentation for a fourth quarter fire drill for all three shifts.

Interview with the maintenance supervisor on February 28, 2024, at 9:30 a.m., confirmed the facility lacked fire drill documentation.





 Plan of Correction - To be completed: 03/29/2024

Facility failed to provide documentation for completion of fire drills.
Facility will complete fire drills as at unexpected times under varying conditions, at least quarterly on each shift.
Proof of fire drill completion will be reviewed at QAPI monthly meeting.

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 two of two generators, affecting the entire facility.

Findings include:

Document review on February 28, 2024, at 11:00 a.m., revealed the facility failed to provide documentation for the following tests:
A. (Monthly) specific gravity or conductance;
B. (Annual) fuel quality test.

Interview with the maintenance supervisor on February 28, 2024, at 11:00 a.m., confirmed the tests had not been completed.




 Plan of Correction - To be completed: 03/29/2024

Facility failed to provide documentation for (A) Monthly Specific gravity Conductance; (B) Annual fuel Quality Testing

Facility has purchased conductance tool for testing. Testing has begun immediately. Audit will be completed monthly and reviewed at monthly QAPI meeting

Facility will have the fuel quality results on file upon completion. Facility has made contact with contracted services in order to get fuel quality tests completed and on file as per new agreement.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to prohibit unauthorized use of electrical devices, affecting one of five wings.

Findings include:

Observation on February 28, 2024, at 1:06 p.m., revealed the Ambassador Hall dining room had a microwave plugged into a surge protector.

Interview with the maintenance supervisor on February 28, 2024, at 1:06 p.m., confirmed the power cord deficiency.




 Plan of Correction - To be completed: 03/29/2024

Survey found that a microwave was attached to a surge suppressor.

Microwave has been removed from surge suppressor and attached directly to wall electrical outlet. Surge suppressor was removed from location.

Maintenance supervisor will educate facility staff that Power strips may not be used as a substitute for adequate electrical outlets in a faciliy. Education will be compelted for all shifts in all departments by end of date of correction.
Education will be completed by maintenance supervisor with sign in sheet as proof of participation.


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