Pennsylvania Department of Health
ABBEYVILLE SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ABBEYVILLE SKILLED NURSING AND 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 March 18, 2024, at Abbeyville Skilled Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #231302
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on March 18, 2024, it was determined that Abbeyville Skilled Nursing and Rehabilitation Center, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected wood frame structure, with a partial basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation on March 18, 2024, between 9:30 AM and 11:30 AM, revealed the facility lacked compartment labeling, resident room capacities, door swings, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances on the portable life safety drawings of the facility, which has an active FSES.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the lack of portable, accurate life safety drawings of the facility.

Plan of Correction - To be completed: 05/10/2024

1.The Maintenance Director located updated floor plan and has been placed in the Safety Binder.
2. Maintenance or designee will review all other floorplans to ensure all information is consistent. A review of plans will occur twice annually.
3.Results of audit reported to QA committee

NFPA 101 STANDARD Means of Egress - General:

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.

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 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain special locking arrangements delayed egress signage, in two of seven smoke zones within the component.

Findings include:

1. Observation on March 18, 2024, between 1:05 PM and 1:40 PM, revealed the exit discharge doors lacked delayed egress signage, at the following locations:

a. 1:05 PM, Steven Hall, by Resident Room 2;
b. 1:40 PM, Arcadia Hall by Resident Room 113.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed exit doors lacked signage.

Plan of Correction - To be completed: 05/10/2024

The Maintenance Director will order signage for discharge doors with delayed egress.
Signage will be posted by 5/3/24.
All exit discharge doors will be audited for delayed egress signage.
Results of audit reported to QA committee

NFPA 101 STANDARD Doors with Self-Closing Devices:

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 - Component: 01 - Tag: 0223
Based on observation and interview, it was determined the facility failed to maintain the rated horizontal fire doors to close and latch within the frame, in two of seven smoke compartments within the component.
Findings include:
1. Observation on January 18, 2024, between 12:30 PM and 1:00 PM, revealed horizontal fire-rated access doors failed to self-close and latch in the frame, at the following locations:
a. 12:30 PM, Buchanan Hall, above smoke doors, by Resident Room 69;
b. 1:00 PM, Steven Hall, above smoke door, by Resident Room 2.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the horizontal fire-rated access doors would not self-close and latch.

Plan of Correction - To be completed: 05/10/2024

Maintenance director or designee will adjust doors in Buchanan Hall, above smoke doors, by room 69 and Stevens Hall above smoke door by Room 2 by 5/3/2024.
All doors will be audited for compliance with regulation once, then monthly for twelve months.
Findings from audit will be submitted to QA committee.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

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.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to maintain exit access to be unobstructed and readily accessible at all times, affecting four of seven smoke compartments within the component.

Findings include:

1. Observation on March 18, 2024, at 11:40 AM, revealed the basement had only one acceptable means of egress.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the basement lacked two acceptable means of egress.

2. Observation on March 18, 2024, at 1:00 PM, revealed the Buchanan Wing egress was through the Dining Room.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the exit location was in an intervening room.

Plan of Correction - To be completed: 05/10/2024

1. The facility respectfully requests that the Department of Health conduct the Fire Safety Evaluation system for the basement and Buchanan Wing egress.

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 - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility lacked installed battery back-up emergency lighting at the transfer switch, affecting the entire component.

Findings include:

1. Observation on March 18, 2024, at 12:05 PM, revealed the Boiler/Transfer Switch Room lacked an installed battery back-up emergency light at the transfer switch.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the Boiler/Transfer Room lacked a battery back-up emergency light for the Automatic Transfer Switch to the Generator.

Plan of Correction - To be completed: 05/10/2024

1.Vendor contacted for battery back up emergency light will be installed above Boiler/Transfer switch room by 5/3/24.
2.All hazardous areas have been inspected for a battery back up light.
3. Light will audited weekly for six weeks
4.Results of audit reported to QA committee

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain rated hazardous area doors to be within the allowed gap margins, in two of seven smoke zones within the component.

Findings include:

1. Observation on March 18, 2024, between 12:45 PM and 1:25 PM, revealed hazardous area rated doors exceeded minimum gap margins, at the following locations:

a. 12:45 PM, 1st floor, Physical Therapy Storage Room door, top and latch side, exceeded 1/8 inch;
b. 1:25 PM, 1st floor, Roosevelt, Boiler Room door, top, exceeded 3/16 inch.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed hazardous area doors exceeded the allowed gap margins.

Plan of Correction - To be completed: 05/10/2024

1. Facility will repair doors to meet gap margins for physical therapy storage room and Roosevelt Boiler room.
2. The Maintenance Director will repair the door by 5/10/24.
3. An audit for hazardous area doors will be done quarterly by maintenance designee.
4. Findings will be submitted to QA committee

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to provide documentation verifying a semi-annual and annual inspections, and bi-annual sensitivity test of the fire alarm system had been performed, affecting the entire component.

Findings include:

1. Review of documentation on March 18, 2024, between 9:30 AM and 11:30 AM, revealed the facility failed to provide documentation verifying a semi-annual visual inspection and annual testing of the fire alarm system had occurred within the previous twelve months.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed facility could not provide documentation of the semi-annual inspection and the annual testing of the fire alarm system.

2. Review of documentation on March 18, 2024, between 9:30 AM and 11:30 AM, revealed the facility failed to provide documentation verifying a sensitivity test was performed in the past two years.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed facility could not provide the results of the bi-annual sensitivity test.

Plan of Correction - To be completed: 05/10/2024

1.The Maintenance Director located semi-annual visual inspection from June and December and annual testing from has been placed in the Safety Binder.
2. Maintenance or designee will maintain records in Safety Binder.
3. A review of records will occur twice annually.
3.Results of audit reported to QA committee

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 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide quarterly, semi-annual, annual, and 5-year sprinkler maintenance documentation, and to maintain the automatic sprinkler piping to be free of extraneous weight, affecting seven of seven smoke zones within the component.

Findings include:

1. Review of documentation on March 18, 2024, between 9:50 AM and 10:00 AM, revealed the facility lacked documentation, for the following:

a. 9:50 AM, wet system, semi-annual, valve supervisory switches and pressure switch waterflow alarm;
b. 9:53 AM, 2nd and 3rd quarterly wet/dry Inspections;
c. 9:56 AM, annual, wet, main drain/control valve test;
d. 9:58 AM, 5-year gauge calibration/replacement;
e. 10:00 AM, 5-year internal valve/pipe inspection.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the lack of documentation for Wet/Dry Sprinkler systems.

2. Observation on March 18, 2024, between 12:33 PM and 1:25 PM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 12:33 PM, Buchanan Hall, above ceiling, by Resident Room 69, various wires;
b. 1:00 PM, Stevens Hall, above ceiling, by Resident Room 2, wires and flex ducting;
c. 1:25 PM, Thaddeus Stevens Hall, Soiled-Utility Room, above ceiling, by Resident Room 30, various wires.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed various items were supported by the sprinkler system.

Plan of Correction - To be completed: 05/10/2024

NHA and Maintenance Director call to confirm system type with vendor; no documentation of having a wet system in place. 5 year inspections will be conducted by vendor by 5/3/24. Wires will be mounted properly to not rest on sprinkler system.
If facility is found to have wet system will have vendor conduct inspections. All dry systems documentation remains in Safety Binder. Wires securely mounted by maintenance director.
Audits of sprinkler system clear from wired will be conducted weekly for six weeks.
Results of audit reported to QA committee.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct and perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on March 18, 2024, between 9:30 AM and 11:30 AM, revealed the facility did not perform fire drills, during the following:

a. 2nd quarter 2023, 1st shift;
b. 2nd quarter 2023, 2nd shift.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed the fire drills were not performed.

Plan of Correction - To be completed: 05/10/2024

1.NHA will educate Maintenance on how to conduct and document a proper fire drill.
2. Maintenance Director will conduct quarterly fire drills for each shift with time recorded.
3.NHA will audit fire drills quarterly for the next twelve months.
4. Findings from fire drills and fire drill schedule will be reported to QA committee.

NFPA 101 STANDARD Electrical Systems - Receptacles:

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.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles to be ground fault interruption (GFI) protected within six feet of a water source, in two of six smoke zones within the component.

Findings include:

1. Observation on March 18, 2024, between 12:05 PM and 1:10 PM, revealed outlets within six feet of a water source were not GFI protected, at the following locations:

a. 12:05 PM, Physical Therapy, above washing machine;
b. 1:10 PM, Stevens Hall, bedside ice maker/machine.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Maintenance Assistant on March 18, 2024, at 2:15 PM, confirmed outlets were not GFI protected.

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