Pennsylvania Department of Health
PREMIER AT PERRY VILLAGE FOR NURSING AND REHABILITATION, LLC
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PREMIER AT PERRY VILLAGE FOR NURSING AND REHABILITATION, LLC
Inspection Results For:

There are  34 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.
PREMIER AT PERRY VILLAGE FOR NURSING AND REHABILITATION, LLC - 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 January 23, 2024, at Premier at Perry Village for Nursing and Rehabilitation, Llc, 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 #161002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2024, it was determined that Premier at Perry Village for Nursing and Rehabilitation, Llc 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, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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 - Component: 01 - Tag: 0291

Based on document review, observation and interview, it was determined the facility lacked documentation verifying the maintenance of battery-powered emergency lighting sources, affecting the entire component.

Findings include:

1. Review of documentation on January 23, 2024, between 8:45 AM and 10:30 AM, it was revealed the facility failed to provide documented monthly and annual testing of battery powered emergency lighting sources.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the lack of documentation for installed back-up emergency light testing.




 Plan of Correction - To be completed: 03/12/2024

The facility will complete monthly and annual testing of battery powered emergency lighting sources.

The Maintenance Supervisor will receive re-education by the Administrator on completing monthly and annual testing of battery powered emergency lighting sources.
The facility will complete monthly and annually audits to be certain that battery powered emergency lighting sources are completed monthly and annually.
Audits will be reviewed at the next QAPI meeting.

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 hazardous area doors, to be within the allowed gap margins, and to positively latch in the frame, in one of four smoke zones within the component.

Findings include:

1. Observation on January 23, 2024, at 11:45 AM, revealed the Kitchen Storage Closet door had a 3/16 of an inch gap, at the top and latch side of door.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the Kitchen Storage Closet door exceeded the allowed gap margins.


2. Observation on January 23, 2024, at 11:48 AM, revealed the Kitchen Storage Closet door failed to close and positively latch in the frame.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the Kitchen Storage Closet door failed to close and latch in frame.



 Plan of Correction - To be completed: 03/12/2024

The Kitchen storage closet door will be adjusted so that the door does not exceed the allowed gap margins. Repairs will be made to the door so that it positively latchs.
The Maintenance Supervisor will receive re-education by the Administrator on the allowed gap margins for interior doors.
The facility will complete an audit of 5 facility doors per week for 4 weeks and then monthly to ensure that the door gap margins due not exceed the allowed gap margins and the doors positively latch when closed. Monthly audits will include hazardous doors and commonly used doors.
Audits will be reviewed at the next QAPI meeting.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324
Based on document review and interview, it was determined the facility failed to provide owner's checks, semi-annual hood cleanings and semi-annual testing of the fixed chemical fire suppression system, in one of four smoke zones within the component.

Findings include:

1. Review of documentation on January 23, 2024, between 8:45 AM and 10:30 AM, revealed the last documented owner's quick check, of the fixed chemical fire suppression system, installed in the Kitchen, was on October 26, 2023.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility failed to conduct the owner's quick checks on the Kitchen's fixed chemical fire suppression system.


2. Review of documentation on January 23, 2024, between 8:45 AM and 10:30 AM, revealed the facility could not provide documentation, verifying the Kitchen exhaust ductwork had been cleaned, on a semi-annual basis. Documentation verified last cycle was completed on January 1, 2023.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide Kitchen ductwork had been cleaned, semi-annually.


3. Review of documentation on January 23, 2024, between 8:45 AM and 10:30 AM, revealed the facility could not provide documentation, verifying the Kitchen's fixed chemical fire suppression system had been tested/maintained, semi-annually. Documentation verified the last inspection was completed on December 11, 2023, but could not provide documentation for the prior semi-annual testing.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide one full year of semi-annual suppression system documentation.



 Plan of Correction - To be completed: 03/12/2024

The kitchen exhaust ductwork will be cleaned on a semi-annual basis. The kitchen's fixed fire suppression system will be tested/maintained semi-annually.
The Maintenance Supervisor will receive re-education by the Administrator on scheduling kitchen exhaust ductwork semi-annually and scheduling the kitchen's fixed fire suppression system testing semi-annually.
The facility will audit semi-annually that these preventative items were scheduled and complete.
Audits will be reviewed at the next QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to provide annual maintenance documentation, repair documentation, pressurized water tank documentation and sprinkler piping system, to be free of extraneous weight, and sprinkler system to be free of obstructions, affecting two of four smoke compartments within the component.

Findings include:

1. Review of documentation on January 23, 2024, between 8:55 AM and 8:59 AM, revealed the facility lacked documentation, of the following testing and inspections:

a. 8:55 AM, Wet System, annual main drain test;
b. 8:56 AM. Wet System, annual, control valves;
c. 8:59 AM. Wet System, quarterly, exterior tank inspections.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide results for the annual testing and inspections.


2. Review of documentation on January 23, 2024, between 8:45 AM and 10:30 AM, revealed the facility lacked documentation, verifying pressure switches had been replaced, which was recommended on the quarterly report, dated September 25, 2023, by Johnson Controls.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide documentation, verifying repairs had been performed, as recommended by the vendor.


3. Review of documentation and interview, on January 23, 2024, between 9:03 AM and 9:11 AM, revealed the facility failed to provide documentation for maintenance/repairs to the pressurized water storage tank for the sprinkler system, which were documented on November 8, 2022, by Pittsburgh Tank and Tower Group, during the internal tank inspection, as listed:

a. 9:03 AM, Wet System, 3/5 internal tank inspection, replace primary manway for compliance with OSHA confined space standards;
b. 9:05 AM, Wet System, 3/5 internal tank inspection, hand washing, wire brush and applying a finish coat of acrylic, which was confirmed during inspection; installing a removable silt stop;
c. 9:07 AM, Wet System, 3/5 internal tank inspection, installing a removable silt stop;
d. 9:09 AM, Wet System, 3/5 internal tank inspection, performing a dry interior cleanout (noted sediment could clog sprinkler heads, rendering sprinkler system failures and deficient);
e. 9:11 AM, Wet System, 3/5 internal tank inspection, performing power tool cleaning, stipe coating and applying an epoxy liner.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide documentation, verifying repairs had been performed by the vendor.


4. Observation on January 23, 2024, at 11:50 AM, revealed flex duct was sitting on the sprinkler piping system, in the 300 Hall, above the ceiling, by the Employee Lounge.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the flex duct was supported by the sprinkler piping system.


5. Observation on January 23, 2024, between 12:15 PM and 12:20 PM, revealed sprinkler heads were subject to a load of lint/dust, at the following locations:

a. 12:15 PM, Laundry Room, Dryer Chase 2 sprinkler heads;
b. 12:17 PM, Laundry Room, Dryer Room 1 sprinkler head;
c. 12:20 PM, Laundry Room, Washer Room 1 sprinkler head.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed sprinkler heads were carrying an accumulated load of lint and dust.



 Plan of Correction - To be completed: 03/12/2024

The facility will schedule annual maintenance of the sprinkler system to include an annual main drain test, annual control valves and a quarterly exterior tank inspection. The facility will schedule pressure switches to be replaced. The facility will also schedule repairs to the water storage tank as recommended by the Pittsburgh Tank and Tower Group in 2022. I am requesting a Time-Limited Waiver for the repairs that are needed to the water storage tank. I emailed the request for the TLW on 2/6/24. The duct work in the 300 hall will not be sitting on top of the sprinkler piping system. The sprinkler heads will be free of dust/lint in the laundry room.
The Maintenance Supervisor and Housekeeping Supervisor will be re-educated on scheduling annual maintenance to the sprinkler system and a quarterly exterior tank inspection. They will also be re-educated on scheduling follow-up repairs as deemed necessary by outside contractors. They will also be re-educated on not having the duct work in the ceiling sitting on top of the sprinkler system. They will also be re-educated on making sure that all sprinkler heads are free of dust/lint.
The facility will audit the TELS system monthly to ensure that all semi-annual and annual inspections are scheduled and complete and that follow-up repairs are scheduled as needed. The maintenance department will audit all ceiling work after vendors have completed necessary work in order to ensure that ductwork is not sitting on sprinkler piping.
Audits will be reviewed at the next QAPI meeting.



NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 - Component: 01 - Tag: 0918
Based on document review and interview, it was determined the facility failed to provide required maintenance and testing documentation and lacked annual fuel quality analysis, for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on January 23, 2024, between 9:30 AM and 9:41 AM, revealed the facility lacked documentation, for generator maintenance and testing, for the following:

a. 9:30 AM, weekly maintenance, last performed November 11 2023;
b. 9:33 AM, monthly maintenance, 30 min load with transfer switch;
c. 9:36 AM, annual load bank;
d. 9:38 AM, 3-year, 4-hour building load;
d. 9:41 AM, 3-year annual fuel quality test was last performed April 18, 2022.

Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide documentation, of the weekly, monthly and annual generator testing and inspections.



 Plan of Correction - To be completed: 03/12/2024

The facility will test the generator weekly. The facility will have a 30 minute load test with transfer switch completed monthly. The facility will have an annual load bank test as well as a 3-year 4 hour building load test as well as an annual fuel quality test.
The Maintenance Supervisor will be re-educated on regulation K0918 for generator testing.
The facility will audit the TELS system monthly to ensure that the appropriate generator testing occurs.
Audits will be reviewed at the next QAPI meeting.



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