Pennsylvania Department of Health
CARING HEART REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 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.


CARING HEART 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 August 21, 2024, at Caring Heart 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 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0000

Facility ID# 191802
Component 01
Main (Cliveden) Building

Based on a Medicare/Medicaid Recertification Survey completed on August 21, 2024, it was determined that Caring Heart Rehabilitation and Nursing Center - Main Cliveden Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 five-story, Type II (222), fire resistive building, with a penthouse, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit and directional signs with continuous illumination, affecting one of five levels in the facility.

Findings include:

11:10 a.m., revealed, on the fifth floor, all emergency exit lights failed to be continuously illuminated.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 10/08/2024

- The fifth floor emergency exit lights illuminate
- Maintenance Staff will be in serviced as to the importance of maintaining exit and directional signs with continuous illumination.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of five levels in the facility.
Findings include:

1.11:12 a.m., revealed, on the fifth floor, above the ceiling of the smoke barrier doors next to resident room 514, multiple open penetrations.

2.11:25 a.m., revealed, on the fifth floor above the ceiling of the smoke barrier door next to resident rehab, multiple open penetrations.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 pm, confirmed the above mentioned deficiencies.

Plan of Correction - To be completed: 10/08/2024

- The fifth floor, above the ceiling of the smoke barrier doors next to resident room 514, multiple open penetrations were sealed with a UL approved stop gap penetration. The fifth floor above the ceiling of the smoke barrier door next to resident rehab, multiple open penetrations were sealed with a UL approved stop gap penetration .
- Maintenance Staff will be in serviced as to the importance of maintain smoke barrier walls free of unsealed penetrations.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 (PREVIOUSLY SACRED HEART MANOR) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting the entire component.

Findings include:

1.11:15 a.m., on the fifth floor, revealed a broken electrical outlet in the main hallway by room 503.

2.11:23 a.m., on the fifth floor, revealed exposed wires in the boiler room of the penthouse along wall opposite roof access door.

3.11:34 a.m., on the fourth floor, B-wing, revealed exposed wires above ceiling mounted light fixture outside room 418.

4.11:34 a.m., on the fourth floor, B-wing, revealed 4 newly installed light fixtures lack bonnet system exposing wiring above mounted fixtures.

5.11:36 a.m., on the fourth floor, lounge pantry revealed broken light switch and missing cover exposing wires.

6.11:43 a.m., on the first floor, kitchen, revealed braker panel frame housing completely detached from wall exposing all electrical wires.

7.12:06 p.m., in the basement, the maintenance shop, revealed extension cord ran through ceiling to power ceiling mounted cord reel.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed above deficiencies.

Plan of Correction - To be completed: 10/08/2024

- The fifth floor broken electrical outlet in the main hallway by room 503 was repaired. The fifth floor exposed wires in the boiler room of the penthouse along wall opposite roof access door were coverd. The fourth floor, B-wing, exposed wires above ceiling mounted light fixture outside room 418 was covered. The fourth floor, B-wing, revealed 4 newly installed light fixtures lack bonnet system exposing wiring above mounted fixtures have bonnets installed. The fourth floor, lounge pantry broken light switch and missing cover exposing wires was repaired. The first floor, kitchen braker panel frame housing completely detached from wall exposing all electrical was repaired.. The basement, the maintenance shop, revealed extension cord ran through ceiling to power ceiling mounted cord reel was removed.
- Maintenance Staff will be in serviced as to the importance of maintaining electrical wiring and equipment as per the code
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months.

Initial comments:Name: BUILDING A CONVERSION - Component: 02 - Tag: 0000

Facility ID# 191802
Component 02
Mt. Airy Building A

Based on a Medicare/Medicaid Recertification Survey completed on August 21, 2024, it was determined that Caring Heart Rehabilitation and Nursing Center - Mt. Airy Building A was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 five-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: BUILDING A CONVERSION - Component: 02 - Tag: 0222

Based on observation and interview, it was determined that the facility failed to maintain egress doors with special locking arrangements, affecting one of five levels.

Findings include:

Observation on August 21, 2024, at 11:10 a.m., revealed, on the fourth floor, the south stair tower emergency egress door failed to release after code was entered by staff member.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the door failed to release.

Plan of Correction - To be completed: 10/08/2024

- The fourth floor, the south stair tower emergency egress door was repaired to release after code is entered.
- Maintenance Staff will be in serviced as to the importance of maintaining egress doors with special locking arrangements.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months.

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: BUILDING A CONVERSION - Component: 02 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain stairways, affecting one of five levels.

Findings include:

Observation on August 21, 2024, at 10:15 a.m. revealed a bed stored under the landing in the south stairway, on the first floor.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the storage within the stair tower.

Plan of Correction - To be completed: 10/08/2024

- The bed stored under the landing in the south stairway, on the first floor was removed.
- Maintenance Staff will be in serviced as to the importance of maintaining stairways.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

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: BUILDING A CONVERSION - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting two of five levels.

Findings include:

Observation on August 21, 2024, revealed the following deficiencies of hazardous area enclosures:

a. 10:50 a.m., on the third floor, the storage room door failed to latch when tested- damaged latch.
b. 11:10 a.m., on the fourth floor, the soiled room door failed to latch when tested- racked in frame.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the hazardous area deficiencies.

Plan of Correction - To be completed: 10/08/2024

- The third floor storage room door latches. The fourth floor soiled room door failed to latches
- Maintenance Staff will be in serviced as to the importance of maintaining fire resistance rating of hazardous areas, in sprinklered locations.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

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: BUILDING A CONVERSION - Component: 02 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

Document review on August 21, 2024, at 9:30 a.m., revealed the May 2024, annual sprinkler inspection report listed the following deficiency. Proof of corrective action was not available at time of survey:

a. The water supply during main drain testing is significantly lower (44.85 to 49.85 PSI) than the hydraulic calculations 08/22/18 through 05/17/24. This makes the sprinkler system to not operate as originally designed. This needs to be investigated. "

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the sprinkler system deficiencies.

Plan of Correction - To be completed: 10/08/2024

- The sprinkler system will operate as originally designed.
- Maintenance Staff will be in serviced as to the importance of maintaining an automatic sprinkler system components.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

A time limited waiver has been submitted

NFPA 101 STANDARD Portable Fire Extinguishers:

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: BUILDING A CONVERSION - Component: 02 - Tag: 0355

Based upon observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were maintained, affecting four of five levels.

Observations on August 21, 2024, revealed cabinet fire extinguisher indicator lights were not illuminated in multiple locations throughout.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the burned-out bulbs.

Plan of Correction - To be completed: 10/08/2024

- The cabinet fire extinguisher indicator lights were repaired.
- Maintenance Staff will be in serviced as to the importance of maintaining portable fire extinguishers.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months.

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: BUILDING A CONVERSION - Component: 02 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls free of unsealed penetrations, affecting one of five levels in the facility.

Findings include:

11:43 a.m., revealed, on the third floor, by resident room 326 a large penetration at the base of the corridor wall.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the defciencies.

Plan of Correction - To be completed: 10/08/2024

- The third floor, by resident room 326 penetration at the base of the corridor wall was repaired.
- Maintenance Staff will be in serviced as to the importance of maintaining corridor walls free of unsealed penetrations.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: BUILDING A CONVERSION - Component: 02 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas outside the facility, affecting one of five levels.

Findings include:

Observation on August 21, 2024, at 8:40 a.m., revealed 2- staff members smoking outside the main entrance directly under the No Smoking sign.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the employee smoking.

Plan of Correction - To be completed: 10/08/2024

- Staff members were in-serviced about smoking in the designated smoking and maintaining smoking areas outside the facility.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

NFPA 101 STANDARD Electrical Systems - Other:

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: BUILDING A CONVERSION - Component: 02 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical systems, affecting two of five levels.

Findings include:

Observations on August 21, 2024, revealed the following electrical system deficiencies:

a. 10:35 a.m., on the ground floor, by doors to Cliveden, abandoned MC wire.
b. 10:50 a.m., on the third floor, the storage room, damaged duplex receptacle.
c. 10:55 a.m., on the third floor, the corridor by room. 354, duplex receptacle missing its cover.
d. 11:00 a.m., on the fourth floor, the storage room, duplex receptacle missing its cover.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the electrical deficiencies.

Plan of Correction - To be completed: 10/08/2024

- The ground floor, by doors to Cliveden, abandoned MC wire was covered. The third floor, the storage room, damaged duplex receptacle was repaired. The third floor, the corridor by room. 354, duplex receptacle missing its cover. The fourth floor, the storage room, duplex receptacle missing its cover was repaired
- Maintenance Staff will be in serviced as to the importance of maintaining protection of electrical systems.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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: BUILDING A CONVERSION - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting two of five levels.

Findings include:

Observations on August 21, 2024, revealed the following electrical deficiencies:

a. 10:40 a.m.. on the ground floor, the dialysis- fridge plugged into extension cord plugged into power strip.
b. 11:00 a.m., on the third floor, the Unit Manager office- fridge into power strip.

Exit interview with the Administrator and Maintenance Director on August 21, 2024, at 12:45 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 10/08/2024

- The ground floor, the dialysis- fridge plugged into extension cord plugged into power strip was removed. The third floor, the Unit Manager office- fridge plugged into the power strip was removed
- Maintenance Staff will be in serviced as to the importance of maintaining the use of electrical devices.
- The Director of Maintenance or designee will audit for compliance. Monthly audits times 3 will continue thereafter with results reported to the QA Committee by the Director of Maintenance or designee for the next three months

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