Pennsylvania Department of Health
RITTENHOUSE POST ACUTE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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RITTENHOUSE POST ACUTE - 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 29, 2024, at Presbyterian Center For Continuing Care, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: RELOCATION - SNF 5TH FLOOR PENN MED RITTENHOUSE - Component: 10 - Tag: 0000

Facility ID# 421102
Component 10
Penn Medicine-Rittenhouse
Continuing Care/Skilled Nursing Unit

Based on a Medicare/Medicaid Recertification Survey completed on August 29, 2024, it was determined that Presbyterian Center For Continuing Care 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 six-story, Type II (222), fire resistive building, with a penthouse and basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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.

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: RELOCATION - SNF 5TH FLOOR PENN MED RITTENHOUSE - Component: 10 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain gas and cylinder storage rooms, affecting the entire facility.

Findings include:

Observation on August 29, 2024, at 10:42 a.m., revealed oxygen tanks stored in the Supply Room. The door to the Supply Room lacked signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Exit interview with the Associate Director of Physical Plant on August 29, 2024, at 10:45 a.m., confirmed the lack of signage.

Plan of Correction - To be completed: 09/13/2024

Facility corrected the signage stating "Caution: oxidizing gas(es) stored within no smoking"
All other like areas were observed, and signs were placed as necessary
Maintenance Director was educated on appropriate signage
NHA/Designee will complete audits 2x per week for 3 weeks then monthly for 3 months to assure appropriate signage is in place. The results of the audits will be submitted to the quality assurance performance improvement committee monthly for review and recommendations including the need for further audits if indicated based on the audit findings.

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