Pennsylvania Department of Health
TUCKER HOUSE NURSING AND REHABILITATION CENTER
Building Inspection Results

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TUCKER HOUSE NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  42 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.
TUCKER HOUSE 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 February 7, 2024 at Tucker House 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 01 - Component: 01 - Tag: 0000


Facility ID #369402
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on February 7, 2024, it was determined that Tucker House Nursing And 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 four-story, Type II (222), fire resistive building, ground, Second, Third, Fourth floors and basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Egress Doors: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0222

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

Findings include:

Observation on February 7, 2024, at 11:42 a.m., revealed, on the ground floor, the staff did not know the unlock code for the exit door by the West Stairtower.

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the staff did not know the exit code.




 Plan of Correction - To be completed: 03/20/2024

Staff made aware of code to exit.
NHA will educate the Maintenance Director on maintaining egress doors
NHA/designee will audit weekly x 4, then monthly X 3.
Findings will be reviewed in the monthly QAPI.

NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

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

Findings include:

Observation on February 7, 2024, at 11:11 a.m., revealed, on the fourth floor, the lights were burnt out in the landing of the exit stairs by resident room 421.

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the burnt out lights.




 Plan of Correction - To be completed: 03/20/2024

Light bulbs replaced.
NHA educated the Maintenance Director on maintaining illumination in areas of egress.
An initial audit was done to ensure areas of egress have proper illumination.
NHA/designee will audit weekly x 4, then monthly X 3.
Findings will be reviewed in the monthly QAPI.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
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 - 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 four of five levels in the facility.

Findings include:

1. Observations on February 7, 2024, between 11:08 a.m. and 11:51 a.m., revealed storage within three feet of electrical panels in the below locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

a. 11:08 a.m., Fourth floor, Electrical Room;
b. 11:21 a.m., Third floor, Electrical Room;
c. 11:28 a.m., Second floor, Electrical Room;

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the storage in front of the electrical panels.

2. Observation on February 7, 2024, at 11:51 a.m., revealed, in the basement Elevator Machine Room, the cover was not installed on the elevator controls.

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the lack of cover.




 Plan of Correction - To be completed: 03/20/2024

Storage within 3 ft of panels were removed.
NHA educated the Maintenance Director on NFPA 70 National Electric Code.
An initial audit was done to ensure compliance around all other panels.
NHA/designee will audit weekly x 4, then monthly X 3.
Findings will be reviewed in the monthly QAPI.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of rubbish and laundry chutes, affecting three of five levels in the facility.

Findings include:

1. Observations on February 7, 2024, between 11:05 a.m. and 11:29 a.m., revealed the doors to chutes would not latch in the following locations:

a. 11:05 a.m., Fourth floor Soiled Laundry;
b. 11:06 a.m., Fourth floor Trash;
c. 11:22 a.m., Third floor, Trash;
d. 11:29 a.m., Second floor, Trash.

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the chute doors failed to latch.

2. Observation on February 7, 2024, at 11:29 a.m., revealed, in the Third floor Trash room, the door to the room had non-fire rated hardware.

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the lack of fire rated hardware.



 Plan of Correction - To be completed: 03/20/2024

Doors to the chutes were fixed and now latch hardware replaced to fire rated hardware.
NHA educated the Maintenance Director on maintaining proper fire resistance for chutes and hardware.
An initial audit was done to ensure all other chutes and hardware are in compliance.
NHA/designee will audit weekly x 4, then monthly X 3.
Findings will be reviewed in the monthly QAPI.

NFPA 101 STANDARD Electrical Equipment - Other: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 Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review and interview on February 7, 2024, at 8:30 a.m., revealed the facility could not produce documentation of weekly inspection of battery voltage.

Exit interview with the Administrator and Maintenance Director on February 7, 2024, at 12:00 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 03/20/2024

Weekly inspection documentation started on battery voltage.
NHA educated the Maintenance Director on maintaining and inspecting the emergency generator.
NHA/designee will audit weekly x 4, then monthly X 3.
Findings will be reviewed in the monthly QAPI.


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