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1001 STERIGERE STREET

NORRISTOWN, PA 19401

EP Program Patient Population

Tag No.: E0007

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness program addressing the patient population, affecting the entire facility.

Findings include:

Documentation reviewed on January 4, 2024, revealed the Facility's Emergency Preparedness plan did not address patient/client population, persons at risk, and the type of services the facility has the ability to provide in an emergency.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the EP plan did not specify the population served within the facility, in the event of an emergency.

EP Testing Requirements

Tag No.: E0039

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) testing program to conduct exercises to test the emergency plan, affecting the entire facility.

Findings include:

Documentation reviewed on January 4, 2024, revealed the facility failed to conduct exercises to test the emergency plan twice per year. Documentation was provided for an individual facility-based exercise conducted in March 2023. A second full-scale community-based, individual, facility-based functional exercise, mock disaster drill, tabletop exercise or workshop led by a facilitator that included a group discussion was not available at the time of survey.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the facility failed to conduct required exercises for the Emergency Preparedness plan.

General Requirements - Other

Tag No.: K0100

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 observation and interview, it was determined the following item(s) did not 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 facility.

Findings include:

Observation and document review made on January 5, 2024, revealed the facility failed to secure plan approval by the Department of Health (Department) prior to initiating alterations to remove fire doors and seal the opening separating the tunnel at the A Wing, ground floor (Building 51).

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024 at 12:30 p.m., confirmed the facility failed to obtain Department-approved plans prior to initiating alterations and renovations.

28 Pa Code § 51.3. Notification (d)

Means of Egress - General

Tag No.: K0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free from obstructions, affecting 1 of four levels (Building 51).

Findings Include:

Observation made on January 5, 2024, revealed the facility was unable to locate keys to exit doors in a timely manner. There were several attempts to locate the appropriate key to Stair B door 1032, 1st floor.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to egress.

Stairways and Smokeproof Enclosures

Tag No.: K0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair enclosures, affecting 1 of four levels (Building 1).

Findings include:

Observation on January 5, 2024, revealed partially sealed conduit penetrations in the corner of the stair wall, First Floor, A wing, short hall, above the stair enclosure door.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unsealed penetrations in the above named location.

Illumination of Means of Egress

Tag No.: K0281

Based on observation and interview, it was determined the facility failed to maintain required illumination of the means of egress, affecting 1 of four levels (Building 1).

Findings Include:

Observation on January 5, 2024, revealed Stair 5 lacked two forms of illumination at the exit discharge, in the event one bulb becomes inoperable, Ground Floor.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the exit discharge required additional illumination.

Exit Signage

Tag No.: K0293

Based on observation and interview, it was determined the facility failed to ensure exit directional signs were installed, affecting 1 of four levels (Building 10).

Findings include:

Observation on January 5, 2024, revealed the Center Hall lacked exit signage, E Wing, Second Floor.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the lack of exit signage.

Vertical Openings - Enclosure

Tag No.: K0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings between floors, affecting 2 of four levels (Building 10).

Findings include:

1. Observation on January 5, 2024, revealed on the First Floor, in the D-1 Nurses' Station Med Room, inside Pipe Chase Closet 1018, there were four (4) unsealed pipes penetrating the floor slab.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unsealed vertical penetrations.


2. Observation on January 5, 2024, revealed there was an opening in the wall above the duct penetrating the shaft wall inside the Cafeteria, First Floor, E Wing. In addition, the installation of perimeter-mounting angles could not be determined.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the vertical openings in the above named locations.

Vertical Openings - Enclosure

Tag No.: K0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting 1 four levels (Building 1).

Findings include:

Observation on January 5, 2024, revealed inside Mechanical Shaft 1088, next to the Laundry Room, there was a large opening in the ceiling and an unsealed duct penetration in the rear of the space. The duct penetration lacked access to verify installation of a fire damper, First Floor, E Wing.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unprotected vertical openings.

Vertical Openings - Enclosure

Tag No.: K0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting 1 of four levels (Building 51).

Findings include:

Observation on January 5, 2024, revealed the fire extinguisher cabinet was recessed into the shaft wall near electrical panel 1C DSGS-1985, First Floor, A Wing.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the integrity of the enclosure was compromised.

Sprinkler System - Maintenance and Testing

Tag No.: K0353

Based on document review and interview, it was determined the facility failed to maintain sprinkler system components in operable condition, affecting 1 of three systems (Building 51).

Findings include:

Documentation reviewed on January 4, 2024, revealed the internal sprinkler inspection & testing report dated February 1, 2022 for the linen chutes indicated only 2 of 3 laundry chute systems were clear and one pipe on the system was corroded. Verification of repairs was not available at the time of inspection.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the deficienct sprinkler components.

Sprinkler System - Maintenance and Testing

Tag No.: K0353

Based on document review and interview, it was determined the facility failed to maintain sprinkler system components in operable condition, affecting 3 of four levels (Building 1).

Findings include:

Documentation reviewed on January 4, 2024, revealed the internal sprinkler inspection & testing report dated February 1, 2022 for the linen chutes and Toggery room indicated they were unable to complete internal testing and were unable to shut the system down. Gauge valves are corroded and there was a clog in the system. The 4" OS&Y valve should be replaced. Verification of repair was not available at the time of inspection.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the deficienct sprinkler components.

Portable Fire Extinguishers

Tag No.: K0355

Based on observation and interview, it was determined the facility failed to ensure fire extinguishers were installed properly, affecting 1 of four levels (Building 10).

Findings include:

Observation on January 5, 2024, revealed in the Second Floor, D-2 short hall, near Room 2011, the recessed fire extinguisher and locator light above the extinguisher had been removed.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the fire extinguisher removal.

Corridor - Doors

Tag No.: K0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors resisted the passage of smoke and positively latched into their frames, affecting 1 of four levels (Building 51).

Findings include:

1. Observation made on January 5, 2024, revealed the Lawyers waiting room corridor door was propped open with a chair. The door had a self-closing device installed, 1st floor.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the corridor door obstruction.

Corridor - Doors

Tag No.: K0363

Based on observation and interview, it was determined the facility failed to maintain positive self-latching on corridor doors, affecting 2 of four floor levels (Building 1).

Findings include:

Observation on January 5, 2024, revealed there was a dogged-down feature on the latching device on the top half of the Med room corridor dutch door, located on each resident sleeping floor level, E Wing.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to door latching.

Corridor - Doors

Tag No.: K0363

Based on observation and interview, it was determined the facility failed to maintain positive self-latching on corridor doors, affecting 2 of four levels (Building 10).

Findings include:

Observation on January 5, 2024, revealed there was a dogged-down feature on the latching device on the top half of the Med room corridor dutch door, located on each resident sleeping floor level, E Wing.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to door latching.

Subdivision of Building Spaces - Smoke Barrie

Tag No.: K0372

Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were free of unsealed penetrations, affecting 1 of five smoke zones (Building 10).

Findings include:

Observation on January 5, 2024, revealed on the First Floor above smoke barrier door 1012, near the Visitation Room 1011, there was a wire cut out penetration through the smoke barrier wall.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the smoke barrier wall penetration.

Utilities - Gas and Electric

Tag No.: K0511

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, affecting 1 of four levels (Building 51).

Findings include:

Observation on January 5, 2024, revealed there was an open junction box with exposed inner wiring above the ceiling, near the smoke barrier partition, outside the Nurses' Station, First Floor, A Wing;

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unprotected electrical wiring.

HVAC

Tag No.: K0521

Based on document review and interview, it was determined the facility failed to maintain HVAC (Heating, Ventilating, and Air Conditioning) equipment in operable condition, affecting 1 out of 205 dampers (Building 1).

Findings Include:

Documentation reviewed on January 4, 2024, revealed the damper inspection & testing report indicated damper 293 was not powered. Verification of repair was not available at the time of survey.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the damper was not functioning.

HVAC

Tag No.: K0521

Based on document review and interview, it was determined the facility failed to maintain HVAC (Heating, Ventilating, and Air Conditioning) equipment in operable condition, affecting 2 out of 205 dampers (Building 51).

Findings Include:

Documentation reviewed on January 4, 2024, revealed the damper inspection & testing report indicated two fire dampers were inaccessible. Verification access had been provided was not available at the time of survey:

a. 183;
b. 268.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the dampers were not inspected.

HVAC

Tag No.: K0521

Based on observation and interview, it was determined the facility failed to maintain protection of Heating, Ventilation, and Air Conditioning (HVAC) systems, affecting 1 of four levels (Building 10).

Findings include:

Observation on January 5, 2024, revealed there was a fire damper approximately one foot from the shaft wall. This was one of three ducts in the passage corridor outside the visitor's lobby, Second Floor, E Wing. In addition, the installation of perimeter-mounting angles could not be determined.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the location of the fire damper.

Electrical Systems - Maintenance and Testing

Tag No.: K0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 1).

Findings include:

1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation the receptacles were tested.

Electrical Systems - Maintenance and Testing

Tag No.: K0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 10).

Findings include:

1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation receptacles were tested.

Electrical Systems - Maintenance and Testing

Tag No.: K0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 51).

Findings include:

1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation the receptacles were tested.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 1).

Findings include:

1. Documentation reviewed performed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections for the emergency generator:

a. Weekly visual inspections of the generator;
b. Monthly battery conductance testing;
c. Annual 90 minute Load Bank testing:
d. No evidence of wet-stacking;
e. three (3) year, four (4) hour load test;
f. Annual fuel quality test.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation.



2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 10).

Findings include:

1. Documentation reviewed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections:

a. Weekly visual inspection of the generator;
b. 30 minute load testing on a consistent basis
(e.g. no load test in 2023 on 1/18, 2/7, 3/14, 5/15, June, 7/24, 9/8, and 11/16);
c. Monthly battery conductance testing;
d. Annual 90 minute Load Bank testing:
e. No evidence of wet-stacking;
f. 3 year, 4-hour load test;
g. Annual fuel quality test.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation.



2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 51).

Findings include:

1. Documentation reviewed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections:

a. Weekly visual inspection of the generator;
b. 30 minute load testing on a consistent basis
(e.g. no load test 9/8/23);
c. Monthly battery conductance testing;
d. Annual 90 minute Load Bank testing:
e. No evidence of wet-stacking;
f. three (3) year, four (4) hour load test;
g. Annual fuel quality test.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation.



2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting.

Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.