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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WEST READING SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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WEST READING 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 January 9, 2024, it was determined that West Reading Skilled Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: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.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on January 9, 2024, at 10:00 AM, revealed the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed since January 18, 2022.

Interview with the Maintenance Director on January 9, 2024, at 10:00 AM, confirmed the lack of documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months.




 Plan of Correction - To be completed: 02/20/2024

This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law.

E-0004
1. The facility cannot retroactively correct the date of review from January 18, 2022.
2. The facility Emergency Preparedness Plan was reviewed during an Ad hoc QA meeting on January 29, 2024.
3. Annual review of the Emergency Preparedness manual will occur again in January of 2025 and annually thereafter.

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


Facility ID #902202
Component #01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 9, 2024, it was determined West Reading 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 four-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system in a continuously reliable operating condition, affecting two of seven smoke compartments within the component.

Findings include:

1. Observation on January 9, 2024, at 12:15 PM, revealed the sprinkler head closest to the corridor door, within Resident Room 419, was missing an escutcheon.

Interview with the Maintenance Director on January 9, 2024, at 12:15 PM, confirmed the missing escutcheon.


2. Observation on January 9, 2024, at 12:50 PM, revealed a brown wire was zip-tied to the sprinkler piping within the 1st floor Boiler Room.

Interview with the Maintenance Director on January 9, 2024, at 12:50 PM, confirmed the wire was supported by the sprinkler system.



 Plan of Correction - To be completed: 02/20/2024

K-0353
1. The facility cannot retroactively correct the missing sprinkler head missing escutcheon. In the Boiler Room, the zip tie was removed from holding the brown wire to the sprinkler pipe.
2. The escutcheon was replaced in Room 419 sprinkler head.
3. A one-time facility wide audit completed to identify any missing escutcheon and replaced as indicated. An audit in the Boiler Room was completed to ensure that no other zip ties were present on the sprinkler pipes.
4. Monthly audits for three months to ensure escutcheons are present, with reports to the QA meeting monthly. Audits for the presence of escutcheons will continue quarterly with a report quarterly to the QA Committee.
An audit was performed in the boiler room to ensure that no zip ties are present on sprinkler pipes with a report to the QA Committee. A policy was written and reviewed with Maintenance staff to audit any work space above ceiling tiles or work done with any sprinkler/water pipes to ensure that nothing is attached to those pipes. Reports to be submitted to the QA Committee quarterly.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: MAIN BUILDING - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain the installation of portable fire extinguishers, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on January 9, 2024, at 12:45 PM, revealed the portable fire extinguisher located within the 1st floor Boiler Room was placed on the ground beneath the mounting bracket.

Interview with the Maintenance Director on January 9, 2024, at 12:45 PM, confirmed the portable fire extinguisher was not mounted to the wall.


 Plan of Correction - To be completed: 02/20/2024

K-0355
1.The facility cannot retroactively correct the fire extinguisher sitting on the floor in the Boiler Room.
2. The fire extinguisher mount was replaced and the fire extinguisher is now mounted properly in the Boiler Room.
3. A one-time facility audit was conducted to ensure proper mounting of the fire extinguisher's in-house.
4. The routine monthly fire extinguisher checks will now include a visual check to ensure proper mounting of all of the fire extinguishers in-house with results reported to the QA meeting monthly for three months and quarterly thereafter.

NFPA 101 STANDARD Corridor - 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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on January 9, 2024, at 1:02 PM, revealed the door to the Laundry Clean Linen Room failed to positively latch within the door frame.

Interview with the Maintenance Director on January 9, 2024, at 1:02 PM, confirmed the door did not latch within the frame.


 Plan of Correction - To be completed: 02/20/2024

K-0363
1. The facility cannot retroactively correct the laundry room door not positively latching.
2. The laundry room door was repaired and now positively latches. Education to maintenance staff on frequency of door audits and reporting requirements to the QA Committee.
3. A one-time facility audit was conducted to ensure doors in the facility positively latch.
4. Corridor doors will be audited monthly to ensure positive latching and corrected immediately when indicated. A summary report will be submitted to the QA Committee monthly for three months then quarterly thereafter.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to provide documentation verifying fire doors had been inspected within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on January 9, 2024, at 10:10 AM, revealed the facility failed to provide documentation verifying fire doors had been inspected since January 19, 2022.

Interview with the Maintenance Director on January 9, 2024, at 10:10 AM, confirmed the lack of documentation verifying fire doors had been inspected within the previous twelve months.


 Plan of Correction - To be completed: 02/20/2024

K-0761
1. The facility cannot retroactively correct the lack of documentation for the annual fire door inspections.
2. The Maintenance Director was educated on the annual requirements of the fire door inspection.
3. A one-time facility wide inspection of fire doors in the facility was conducted.
4. The results of the facility wide inspection of the fire doors will be reported to the QA committee. The next annual fire door inspection will be completed In February of 2025.


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