Pennsylvania Department of Health
TREMONT HEALTH & REHABILITATION CENTER
Building Inspection Results

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TREMONT HEALTH & REHABILITATION CENTER
Inspection Results For:

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TREMONT HEALTH & REHABILITATION 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 February 7, 2024, at Tremont Health & 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 - Component: 01 - Tag: 0000


Facility ID #271102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 7, 2024, it was determined that Tremont Health & Rehabilitation 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 (000), unprotected wood frame structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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 observation and interview, it was determined the facility failed to maintain battery back-up emergency lighting fixtures, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on February 7, 2024, at 11:48 AM, revealed the battery back-up emergency lighting fixture within the 600 Hall Men's Bathroom failed to illuminate when tested.

Interview with the Director of Maintenance on February 7, 2024, at 11:48 AM, confirmed the lighting fixture failed to illuminate when tested.


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

1)The battery backup lightening fixture was repaired. Maintenace will conduct weekly audits on the emergency lightening to ensure emergency lights are illuminating properly. Checks will be documented. The NHA will and or designee will review the documentation to ensure compliance.

2)The QAPI committee will review the audits monthly and will provide recommendations. The QAPI committee will review monthly until substantial compliance has been achieved and maintained for a period.

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 the smoke resistance of hazardous area enclosures, affecting two of three smoke compartments within the component.

Findings include:

1. Observation on February 7, 2024, at 11:40 AM, revealed the interior of the 600 Hall Soiled Linens Room had sections of drywall missing where a water leak had previously occurred.

Interview with the Director of Maintenance on February 7, 2024, at 11:40 AM, confirmed the missing drywall on the interior of the room.


2. Observation on February 7, 2024, at 12:16 PM, revealed the door to the 100 Hall Soiled Linens Room failed to positively latch within the door frame.

Interview with the Director of Maintenance on February 7, 2024, at 12:16 PM, confirmed the door did not latch within the frame.


3. Observation on February 7, 2024, at 12:33 PM, revealed the door to the 840 Hall Soiled Linens Room failed to positively latch within the door frame.

Interiew with the Director of Maintenance on February 7, 2024, at 12:33 PM, confirmed the door did not latch within the frame.




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

1) Drywall in the interior of the 600 hall Soiled linen has been repaired. Repairs will occur at time of occurrence.
100 hall soiled linen has been repaired and latches within the door frame.
840 hall soiled linen has been corrected.

2) A one-time facility wide audit will be completed to ensure doors are latching properly. Repairs will occur as deemed necessary.
The maintenance Director/and designee will conduct and document weekly audits. The reports will be reviewed by the QAPI committee monthly until substantial compliance is achieved and maintained.




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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system in a continuously reliable operating condition, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on February 7, 2024, at 11:50 AM, revealed the sprinkler head protecting the 400 Hall Soiled Linens Room was exposed at the level of the suspended ceiling, with no ceiling tile in place to restrict the passage of heat to the interstitial space above.

Interview with the Director of Maintenance on February 7, 2024, at 11:50 AM, confirmed the missing ceiling tile and exposed sprinkler head.


2. Observation on February 7, 2024, at 12:18 PM, revealed the sprinkler head closest to the corridor door within Resident Room 308 was missing an escutcheon.

Interview with the Director of Maintenance on February 7, 2024, at 12:18 PM, confirmed the missing escutcheon.


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

1) The sprinkler head ceiling tile protecting the 400-hall soiled linen room was replaced.
The escutcheon within resident room 308 was replaced.

2) A one-time facility audit will be completed to ensure each sprinkler has an escutcheon and that ceiling tiles are in place to restrict the passage of heat to the interstitial space.

3)Maintenace/designee will complete 5 random audits monthly to ensure placement of the escutcheon and ceiling tiles.

4)The QAPI committee will review monthly and provide recommendation as indicated. The committee will review monthly until a period of substantial has been achieved and maintained for a period of three months.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - 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 - Component: 01 - Tag: 0920
Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on February 7, 2024, at 12:01 PM, revealed a receptacle multiplier supplying electrical power to a surge suppressor and a refrigerator within the Admissions Office.

Interview with the Director of Maintenance on February 7, 2024, at 12:01 PM, confirmed the use of a receptacle multiplier.


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

1)The receptacle multiplier and the surge protector were removed from the admissions office.

2) A one-time facility audit will be completed to ensure there are no surge protectors in use.

3) Maintenance/designee will complete a monthly walk through to ensure there are no surge protectors in use.

4) The QAPI committee will review monthly and provide recommendations as indicated. The QAPI will review monthly until a period of substantial compliance has been achieved for a period of three months.

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