Pennsylvania Department of Health
PENNYPACK 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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PENNYPACK 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 August 8, 2024, at Pennypack 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# 941002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 8, 2024, it was determined that Pennypack 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 one-story, Type III (200), unprotected ordinary structure, with a partial 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 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.

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 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to verify a full flow trip test had been performed, within the last three years, for the dry sprinkler system, which serves the entire component.

Findings include:

1. Review of documentation on August 8, 2024, at 11:30 AM, revealed the facility could provide documentation that a three year, full flow trip test had been performed on the dry sprinkler system since 2020.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on August 8, 2024, at 1:00 PM, confirmed the facility could not verify that a three year full trip test of the dry sprinkler system had been performed since 2020.

Plan of Correction - To be completed: 09/16/2024

1.Facility contacted sprinkler company Johnson Controls to have full flow trip test preformed on dry system. They have us scheduled for 8/23

2. Facility to educate maintenance director was provided with education on sprinkler system testing including frequency of testing.

3. Maintenance Director, or designee, to complete weekly audits x4 to ensure full flow trip test has been completed.

4. Results of audits to be reviewed at monthly QAPI for any further recommendation.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 01 - Component: 01 - Tag: 0355

Based on document review, observation and interview, it was determined the facility failed to have the fire extinguishers serviced, within the last 12 months, in four of four smoke zones within the component.

Findings include:

1. Review of documentation and observation on August 8, 2024, between 11:00 AM and 1:00 PM, revealed the facility did not have the annual fire extinguisher maintenance performed, within the last 12 months. The last maintenance and inspection had been performed in May of 2023.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on August 8, 2024, at 1:00 PM, confirmed the fire extinguisher annual maintenance and inspection had not been performed.

Plan of Correction - To be completed: 09/16/2024

1. Facility contacted the fire extinguisher vendor Johnson Controls and will complete a full building inspection for all fire extinguishers on August 22, 2024. Copies of the report will be kept with the maintenance director and NHA

2. Maintenance director was given education on fire extinguisher inspection frequency and documentation.

3. Maintenance Director, or designee, to complete weekly audits x4 to ensure all fire extinguishers have been inspected.

4. Results of audits to be reviewed at monthly QAPI for any further recommendation.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors, to be free of impediment to closing, in one of four smoke zones within the component.

Findings include:

1. Observation on August 8, 2024, at 12:30 PM, revealed the Dining Room door had a walker placed with the lets on either side of one of the leaves of the door, preventing it from being closed.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on August 8, 2024, at 1:00 PM, confirmed the Dining Room door was obstructed from closing.

2. Observation on August 8, 2024, at 12:38 PM, revealed the Janitor's Closet door was obstructed from closing by the frame, and could not positively latch.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on August 8, 2024, at 1:00 PM, confirmed the Janitor's Closet door was not able to be closed.

Plan of Correction - To be completed: 09/16/2024

1. Walker was removed from fire door immediately and maintenance to repair housekeeping closet door to ensure it latches correctly.

2. Facility to educate all staff that nothing can impede closure of fire doors. Facility will reeducate maintenance staff that all doors with closer arms must latch securely into the door frame.

3. Maintenance director, or designee, to audit housekeeping door to ensure it latches properly and nothing is impeding the closure of fire doors weekly x4 weeks.

4. Results of audits to be reviewed at monthly QAPI for any further recommendation

Initial comments:Name: VESTIBULE - Component: 02 - Tag: 0000

Facility ID# 941002
Component 02
Vestibule Addition

Based on a Medicare/Medicaid Recertification Survey completed on August 8, 2024, at Pennypack Nursing and Rehabilitation Center, it was determined there were no deficiencies identified under the 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 noncombustible structure, which is fully sprinklered.

Plan of Correction:

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