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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 surveys for this facility. Please select a date to view the survey results.

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STATESMAN 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 27, 2024, it was determined Statesman Health & Rehabilitation Center was not in compliance as related to the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

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.

§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..

Observations:
Name: - Component: -- - Tag: 0041

Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Findings include:

Review of documentation on February 27, 2024, at 11:00 a.m., revealed the facility failed to perform and document the required monthly testing/function of the automatic transfer switch, that a delay of not more than ten seconds shall be permitted to emergency power.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed emergency generator transfer switch testing/function deficiency.

Plan of Correction - To be completed: 04/22/2024

Weekly testing of the generator and transfer switch continue, transfer switch has been added to the weekly audit. Maintenance Director and Maintenance Staff educated on the required monthly testing/function of the transfer switch of the generator and it being present on the audit sheet.
NHA/designee will audit the weekly testing/function of the transfer switch x3 months to ensure its completion.

Initial comments:Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0000

Facility ID# 193702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined Statesman Health & Rehabilitation Center 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 one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of five smoke compartments.

Findings include:

Observation on February 27, 2024, at 8:20 a.m., revealed the self-closing door to the dry storage room in the kitchen would not self-close and latch in its frame when tested.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed self-closing door deficiency.

Plan of Correction - To be completed: 04/22/2024

0223
Self-closing door in Dry Storage adjusted and latching properly. Maintenance Director and Maintenance staff educated that all self-closing doors must latch and close properly.
Maintenance Director/designee will randomly audit 3 self-closing doors per week to assure they latch and close properly.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to perform the required annual visual fire alarm system inspection, affecting the entire facility.

Findings Include:

Review of documentation and interview on February 27, 2024, at 11:00 a.m., revealed the facility failed to perform the required annual fire alarm system inspection.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed semi-annual visual fire alarm system inspection deficiency.

Plan of Correction - To be completed: 04/22/2024

0345
Annual visual fire alarm system inspection scheduled for April 8, 2024. All fire alarm testing will be conducted in accordance to code guidelines. Maintenance Director and Maintenance staff educated that all fire alarm testing will be conducted in accordance to code guidelines. Maintenance Director will schedule an annual and semi-annual fire alarm inspection with the vendor for the next five years.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting two of five smoke compartments.

Findings include:

Observation on February 27, 2024, revealed the following automatic sprinkler system deficiencies:

a) 8:27 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. The suspended ceiling in the laundry room behind the dryers was drooping down leaving a large, unsealed gap between the ceiling tiles:
b) 8:34 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were miss-aligned ceiling tiles in the B-wing utility closet:
c) 8:31 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the B-wing respiratory storage room:
d) 8:41 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were unsealed conduit penetration in the B-wing nurse station ceiling above the electrical box.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/22/2024

0353
Suspended ceiling behind the dryers, miss-aligned ceiling tiles in B wing utility closet, and unsealed conduit penetration at B wing Nurses station repaired and sealed. All items stored above the 18-inch horizontal sprinkler plane in the Respiratory Storage closet moved down below the plane.
Maintenance Director/staff and Respiratory Therapist educated on maintaining a smoke/heat resistive ceiling, and storage below the 18-inch horizontal sprinkler plane.
Maintenance Director/designee will randomly audit 3 areas per week to assure that ceiling tiles are intact to maintain a smoke/heat resistive seal, horizontal sprinkler planes ae being maintained in storage areas, and no unsealed conduits present above ceiling tile.

NFPA 101 STANDARD HVAC:

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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to ensure fire dampers were inspected within the required four-year period, affecting the entire facility.

Findings include:

Review of documentation on February 27, 2024, at 11:00 a.m., revealed the facility failed to perform the required four-year fire damper testing/inspection in accordance with NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives. The most recent damper testing/inspection was performed on October 21, 2019.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed four-year damper testing/inspection deficiency.

Plan of Correction - To be completed: 04/22/2024

0521
Four-year fire damper testing/inspection is scheduled for April 8th and 9th, 2024. Maintenance Director and Maintenance staff educated on the requirement of Four-year fire damper testing. Maintenance Director will work with vendor proactively on scheduling the next four-year inspection.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 (ORIGINAL BUILDING) - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Findings include:

Review of documentation on February 27, 2024, at 11:00 a.m., revealed the facility failed to perform and document the required monthly testing/function of the automatic transfer switch, that a delay of not more than ten seconds shall be permitted to emergency power.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed emergency generator transfer switch testing/function deficiency.

Plan of Correction - To be completed: 04/22/2024

0918
Weekly testing of the generator and transfer switch continue, transfer switch has been added to the weekly audit. Maintenance Director and Maintenance Staff educated on the required monthly testing/function of the transfer switch of the generator and it being present on the audit sheet.
NHA/designee will audit the weekly testing/function of the transfer switch x3 months to ensure its completion.

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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in three instances, affecting two of five smoke compartments.

Findings include:

Observation on February 27, 2024, revealed the following electrical wiring systems and equipment deficiencies:

a) 8:53 a.m., there was a microwave and a refrigerator plugged into a power strip in the business office:
b) 9:11 a.m., there was a refrigerator plugged into a power strip in the A-wing sprinkler room office:
c) 9:16 a.m., there was a refrigerator plugged into a power strip in the A-wing med room.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed electrical wiring systems and equipment deficiencies.

Plan of Correction - To be completed: 04/22/2024

0920
Power strips removed from the Business Office, A wing sprinkler room office, and A wing med room.
Maintenance Director and Maintenance staff educated to the maintaining of electrical wiring systems and equipment.
Maintenance Director/designee will audit 3 areas per week x3 months to assure no power strips are being utilized outside of the electrical wiring system and equipment protocol.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain medical gas storage requirements in two instances, affecting one of five smoke compartments

Findings include:

Observation on February 27, 2024, revealed the following oxygen storage deficiencies:

a) 8:49 a.m., there was an unsecured oxygen cylinder in the C-wing shower:
b) 8:51 a.m., there was an unsecured oxygen cylinder in the C-wing tub room.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed oxygen storage deficiencies.

Plan of Correction - To be completed: 04/22/2024

0923
Oxygen cylinders removed immediately from C-wing shower and C-wing tub room. Nursing, Housekeeping and Maintenance Department educated on medical gas storage requirements.
Maintenance Director/designee will audit 3 areas weekly x3months to assure oxygen cylinders are stored per medical gas storage protocol.

Initial comments:Name: BUILDING 02 (PHYSICAL THERAPY BUILDING) - Component: 02 - Tag: 0000

Facility ID# 193702
Component 02
Physical Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined Statesman Health & Rehabilitation Center 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 one-story, Type V (111), protected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: BUILDING 02 (PHYSICAL THERAPY BUILDING) - Component: 02 - Tag: 0345

Based on documentation review and interview it was determined the facility failed to perform the required annual visual fire alarm system inspection, affecting the entire facility.

Findings Include:

Review of documentation and interview on February 27, 2024, at 11:00 a.m., revealed the facility failed to perform the required annual visual fire alarm system inspection.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed semi-annual visual fire alarm system inspection deficiency.

Plan of Correction - To be completed: 04/22/2024

0345

Annual visual fire alarm system inspection scheduled for April 8, 2024. All fire alarm testing will be conducted in accordance to code guidelines. Maintenance Director and Maintenance staff educated that all fire alarm testing will be conducted in accordance to code guidelines. Maintenance Director will schedule an annual and semi-annual fire alarm inspection with the vendor for the next five years.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 (PHYSICAL THERAPY BUILDING) - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Findings include:

Review of documentation on February 27, 2024, at 11:00 a.m., revealed the facility failed to perform and document the required monthly testing/function of the automatic transfer switch, that a delay of not more than ten seconds shall be permitted to emergency power.

Interview with the Director of Nursing and the Maintenance Director on February 27, 2024, at 1:00 p.m., confirmed the listed emergency generator transfer switch testing/function deficiency.

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