Pennsylvania Department of Health
CRANBERRY PLACE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CRANBERRY PLACE
Inspection Results For:

There are  52 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.
CRANBERRY PLACE - 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 24, 2024, at Cranberry Place, 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 # 381602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 24, 2024, it was determined that Cranberry Place 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, with a partial basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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 observation and interview, the facility failed to install carbon monoxide detectors, per PA Act #48, in one of over five required areas.

Findings Include:

Observation on January 24, 2024, at 9:42 a.m., revealed there were no carbon monoxide detectors installed in or around the boiler room per the PA Act #48.

Interview with the maintenance supervisor on January 24, 2024, at 9:42 a.m., confirmed the above deficiency existed.







 Plan of Correction - To be completed: 02/19/2024

- New CO2 detectors were placed around the boiler room every 15 feet from the equipment as per Act #48 on 2/6/24. The Nursing home administrator educated the maintenance director on ensuring CO2 detectors are installed and properly placed. CO2 detectors will be checked monthly for four months. The NHA will monitor system compliance monthly moving forward and report quarterly QAPI.
NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0133

Based on observation and interview, the facility failed to meet multiple occupancy construction type requirements, for one of one fire barrier.

Findings include:

Observation on January 24, 2024, at 11:00 a.m., revealed the basement corridor wall that separates dialysis had two 2"x2" openings in the two-hour rated wall.

Interview with the maintenance supervisor and administrator on January 24, 2024, at 11:00 a.m., confirmed the above deficiency.




 Plan of Correction - To be completed: 02/19/2024

The two-hour separation wall was repaired on 1/25/24. The Nursing home administrator educated the maintenance director on ensuring all penetrations are sealed properly after the outside vendor's completed work. The maintenance director will inspect project areas the same day to ensure no penetration has occurred. Random checks to ensure no firewall penetration occurs monthly for four months. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.
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 maintain emergency lighting testing, affecting the entire facility.

Findings include:

Document review on January 24, 2024, at 9:49 a.m., revealed the facility lacked documentation for an annual 90-minute test of the battery back-up lighting.

Interview with the maintenance supervisor on January 24, 2024, at 9:49 a.m., confirmed the emergency lighting deficiency.




 Plan of Correction - To be completed: 02/19/2024

The Emergency light test 90 minutes was completed on 1/25/2024. The Nursing home administrator educated the maintenance director on ensuring the 90-minute testing must be completed annually. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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, the facility failed to maintain the fire barrier in one of over five hazardous areas.
Findings include:
Observations on January 16, 2024, between 9:32 a.m. and 9:44 a.m., revealed the boiler room failed to maintain a one-hour fire barrier requirement in the following locations:
A.) (9:32 a.m.) The drywall near the water heaters had open joints at the seams and deterioration at floor level, reducing the required one-hour rating;
B.) (9:44 a.m.) The rated masonry wall in the boiler room had an open penetration.

Interview with the maintenance technician on January 16, 2024, at 9:44 a.m., confirmed the above fire barrier deficiencies.












 Plan of Correction - To be completed: 02/19/2024

The drywall near the Heater and Masonry wall in the boiler room were repaired with fireproof material on 1/25/2024. The maintenance director was educated on the safety of ensuring fire barrier walls are sealed. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.
NFPA 101 STANDARD Cooking Facilities: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.
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 01 - Component: 01 - Tag: 0324

Based on document review and interview, the facility failed to maintain cooking facility requirements for one of one kitchen.

Findings include:

Document review on January 24, 2024, at 9:24 a.m., revealed the facility's most-recent semi-annual kitchen hood suppression testing and maintenance report (dated September 25, 2023), noted the following:
A. "Cylinders out-of-date (6-year and/or hydrostatic test)".

Interview with the maintenance supervisor on January 24, 2024, at 9:24 a.m., confirmed the kitchen suppression deficiency at time of the survey.




 Plan of Correction - To be completed: 02/19/2024

The Cylinders out-of-date (6 years) Kitchen. The company was contacted a quote was received and sent the work is scheduled to occur on 2/13/2024. The Nursing home administrator educated the maintenance director on timely receiving and reviewing reports to ensure they were correct and appropriate documentation was received. The NHA will monitor system compliance monthly moving forward and report quarterly QAPI.
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 document review and interview, the facility failed to maintain sprinkler system maintenance and testing for one of two sprinkler systems.

Findings include:

Document review on January 24. 2024, at 10:30 a.m., revealed the wet sprinkler systems testing/inspection report (dated December 5, 2023), listed a supervisory alarm deficiency. The facility could not provide documentation the deficiency was corrected.

Interview with the maintenance supervisor on January 24, 2024, at 10:30 a.m., confirmed the deficiency at the time of the survey.



Based on observation and interview, it was determined that the facility failed to maintain the fire sprinkler system for one of over thirty sprinkler heads.

Findings Include:

Observation on January 24, 2024, at 9:16 a.m., revealed the basement laundry dry room had a sprinkler head covered with a layer of dust / lint. A build-up of material can insulate the sprinkler thermal element, impacting the temperature activation/response time. The build-up of material can also cause inadequate spray coverage.

Interview with the maintenance supervisor on January 24, 2024, at 9:16 a.m., confirmed the above sprinkler head deficiency.






 Plan of Correction - To be completed: 02/19/2024

The sprinkler heads were cleaned on 1/25/24 in the laundry. The maintenance director received an education regarding the importance of sprinkler heads being dust-free. The sprinkler heads will be randomly monitored monthly for 4 months. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.
NFPA 101 STANDARD Electrical Systems - Other:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on one of over 60 junction boxes.

Findings include:

Observation on January 24, 2024, at 9:42 a.m., revealed the boiler room had a junction box that was missing a cover plate.

Reference: NFPA 70-314.28 (C)

Interview with the maintenance supervisor on January 24, 2024, at 9:42 a.m., confirmed the electrical system deficiency.




 Plan of Correction - To be completed: 02/19/2024

The junction box cover was placed on 1/252024. The maintenance manager was educated on the importance of checking to make sure the junction boxes are all covered. The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI
NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, the facility failed to ensure electrical receptacles were tested at patient bed locations, affecting the entire facility.

Findings include:

Document review on January 24, 2024, at 9:06 a.m., revealed the facility could not provide documentation that the electrical receptacles in patient care rooms and at deep sedation bed locations were tested for non-hospital grade receptacles at intervals not exceeding 12 months, and that hospital grade receptacles were tested based on documented performance data. Receptacle testing should include the following:
A. Visual inspection of physical integrity;
B. Correct polarity of the hot and neutral connections;
C. Retention force of the grounding blade (except locking-type receptacles) shall weigh less than 115g (4 oz).

Interview with the maintenance supervisor on January 24, 2024, at 9:06 a.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 02/19/2024

Electrial outlet testing was completed on the test was completed 2/21/24 through 2/22/2024. The Nursing home administrator educated the maintenance director on timely receiving and reviewing reports to ensure they were correct and appropriate documentation was received. . The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.
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 emergency generators for one of one emergency generator.

Findings include:

Observation on January 24, 2024, at 9:55 a.m., revealed the facility lacked documentation that the emergency generator was exercised once every 36 months for four continuous hours.

Interview with the maintenance supervisor on January 24, 2024, at 9:55 a.m., confirmed the emergency generator exercise documentation was unavailable at the time of the survey.




 Plan of Correction - To be completed: 02/19/2024

4-hour full-load Generator run was completed on1/25/24. The Nursing home administrator educated the maintenance director on ensuring the Generator testing to be completed timely. . The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical equipment in one of over fifty rooms.

Findings include:

Observation on January 24, 2024, at 10:05 a.m., revealed the basement maintenance department had a three-to-one extension cord plugged into a surge protector.

Interview with the administrator on January 24, 2024, at 10:05 a.m., confirmed the extension cord was deficient and removed it on-site.






 Plan of Correction - To be completed: 02/19/2024

The power strip was removed from the maintenance office in front of the surveyor. The maintenance director received education on not plugging an extension cord into a power strip. . The NHA will monitor system compliance monthly moving forward and report quarterly to QAPI.



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