Pennsylvania Department of Health
WILLIAMSPORT SOUTH REHABILITATION AND NURSING CENTER
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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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.


WILLIAMSPORT SOUTH REHABILITATION AND NURSING 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 26, 2024, at Williamsport South Rehabilitation and Nursing 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 01 - Component: 01 - Tag: 0000

Facility ID# 641502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 26, 2024, it was determined that Williamsport South Rehabilitation and Nursing 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress in one location, affecting one of one floor.

Findings include:

1. Observation on February 26, 2024, at 9:23 a.m., revealed an accumulation of storage items, located throughout the basement-level, exit access corridor system.

Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, from 11:15 a.m to 11:30 a.m., confirmed the means of egress deficiency.

Plan of Correction - To be completed: 03/27/2024

211-Means of Egress
Cited: Lower level removed of storage items
Like: Facility audit will be completed to ensure means of egress is not compromised.
Education: NHA will educate Maintenance Director on accumulation of storage items.
Audit: Maintenance Director/designee will audit lower level on accumulation of storage items weekly x4 weeks. Results will be taken through QAPI.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower, affecting one of two floors.

Findings include:

1. Observation on February 26, 2024, between 9:19 a.m., and 9:20 a.m., revealed the following:

a. 9:19 a.m., the basement-level, Dietitian Office door was held open by unapproved means, and opened into the adjacent stair tower enclosure.
b. 9:20 a.m., the Dietitian Office door frame assembly, lacked a stamp, or label, denoting it as "fire-rated."

Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, from 11:15 a.m to 11:30 a.m., confirmed the stair tower enclosure deficiencies.

Plan of Correction - To be completed: 03/27/2024

225-Smokeproof Enclosures
Cited: Dietitian office door will not be held open by unapproved means. The door frame to the dietitian's office will show the stamp or label, denoting it as fire-rated.
Like: Facility sweep will be completed to ensure door frames show the proof of being fire rated.
Education: NHA/designee will educate the management team of not permitted doors to be held open by unapproved means.
Audit: Maintenance Director/designee will randomly audit three different areas of the facility weekly x 4 weeks to ensure doors are not held open by unapproved means. Results will be taken through QAPI.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 multiple hazardous area enclosures, affecting one of two floors.

Findings include:

1. Observation on February 26, 2024, between 9:35 a.m., and 9:45 a.m., revealed the following basement-level, hazardous area enclosure door deficiencies.

a. 9:35 a.m., storage room doors, closest to stair tower enclosure, held open by unapproved means.
b. 9:38 a.m., self-closing device removed from Housekeeping Storage.
c. 9:38 a.m., Mattress Storage held open by unapproved means.
d. 9:39 a.m., PT/OT Storage held open by unapproved means.
e. 9:40 a.m., PT Storage II held open by unapproved means.
f. 9:41 a.m., door hardware removed from PT Storage Room II door.
g. 9:42 a.m., Mattress Storage Room lacked a self-closing device.
h. 9:43 a.m., LL/PT Room lacked a self-closing device.
i. 9:44 a.m., LL/OT Room lacked a self-closing device.

Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, from 11:15 a.m to 11:30 a.m., confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 03/27/2024

321-Hazardous Areas
Cited: The following doors were secured appropriately and or repaired appropriately.
- Storage room doors, closest to stair tower enclosure held open by unapproved means.
- Self-closing device removed from housekeeping storage
- Mattress storage door held open by unapproved means.
- PT/OT storage door held open by unapproved means.
- PT Storage II held open by unapproved means.
- Door hardware removed from PT storage room II door.
- Mattress storage room lacked self-closing device
- LL/PT room lacked a self closing device.
- LL/OT room lacked a self closing device.
Like: Maintenance Director/designee will complete audit to ensure storage room doors in lower level are not held open by unapproved means.
Education: NHA/designee will educate Maintenance Director on appropriate door closures.
Audit: Maintenance Director/designee will audit three doors per week x 4 weeks in the lower level to ensure appropriate storage. The results will be taken through 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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three locations, affecting two of two floors.

Findings include:

1. Observation on February 26, 2024, between 9:10 a.m., and 10:55 a.m., revealed the following:

a. 9:10 a.m., two escutcheon plates were missing within the first floor, Main Entrance area.
b. 10:00 a.m., storage items were located within eighteen inches of an adjacent sprinkler head assembly, located within the basement-level, OT/Speech Room closet.
c. 10:55 a.m., two transfer grills were located within the first floor, PT/OT, ceiling assembly.

Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, from 11:15 a.m to 11:30 a.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 03/27/2024

353-Sprinkler System
Cited: Two escutcheon plates were replaced in lobby. Item was removed from closet in therapy gym that exceeded 18 inches to the ceiling. Two transfer grills located within the first floor, PT/OT gym ceiling were repaired.
Like: Audit completed facility wide of escutcheon plates to ensure all have escutcheon plates.
Education: NHA/designee will educate the Maintenance director on need for escutcheon plates, 18 inches to sprinkler heads guidance, and ceiling transfer grills.
Audit: Maintenance Director/designee will audit two different areas of the facility weekly x 4 weeks to ensure items do not exceed the 18 inches to a sprinkler head and to ensure sprinklers have escutcheon plates. The results will be taken through QAPI.

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 corridor doors on one of one floors of the component.

Findings include:

1. Observation on February 26, 2024, between 11:40 a.m. and 11:41 a.m., revealed the following doors were not smoke tight, or door handle needs adjusted:

a. At 10:40 a.m., 1st floor, room 26 door was not smoke tight while latched in the frame.

b. At 10:41 a.m., 1st floor, room 25 door handle needs adjusted to securely open and close the door.

Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, at 11:15 a.m to 11:30 a.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 03/27/2024

363- Corridor Doors
Cited: Room 26 door was repaired to be smoke tight while latched in the frame. Room 25 door handle was adjusted to securely open and close the door.
Like: Resident doors and door handles were audited to ensure they remain smoke tight and door handles are secure.
Education: NHA/designee will educate maintenance director on smoke tight doors and secure door handles.
Audits: Maintenance Director will audit one hall per week x 4 weeks to ensure doors are smoke tight and door handles are secured. The results will be taken through QAPI.

NFPA 101 STANDARD HVAC:

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.

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning in two locations, affecting two of two floor.

Findings include:

1. Observation on February 26, 2024, between 9:50 a.m., and 10:12 a.m., revealed the following:

a. 9:50 a.m., the basement-level, supply air duct, located adjacent to the Maintenance Office, lacked an access panel for inspection of the fire damper, which must be located at the floor slab assembly.
b. 10:12 a.m., the supply, and return air duct work fire dampers, which are located at the Nurse Station, and supplies the Training Room below, are not currently serviced.

Interview at the time of the exit conference with the Adminstrator and Facilities Manager on February 26, 2024, from 11:15 a.m to 11:30 a.m., confirmed the HVAC deficiencies.

Plan of Correction - To be completed: 03/27/2024

521-HVAC
Cited: Lower level supply air duct located adjacent to the maintenance office, lacked an access panel for inspection for fire damper was corrected. The supply and return air duct work fire dampers, located at the nurses station, and supplies the training room below, have been serviced.
Like: A facility audit was completed on 3/7/24 by Quality Air, who inspected all fire dampers (9) in the facility.
Education: NHA/designee will educate the maintenance director on importance of access panel for inspection for the supply air ducts in the lower level and ensuring the supply and return air ducts are serviced.

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