Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT BLUE RIDGE, THE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT BLUE RIDGE, THE
Inspection Results For:

There are  33 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.
GARDENS AT BLUE RIDGE, THE - 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 June 11, 2019, at The Gardens at Blue Ridge, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID# 022202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2019, it was determined that The Gardens at Blue Ridge 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 one-story, Type III (200), unprotected ordinary structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the rating of doors at the common wall doors, in one of two building separations within the component.

Findings include:

1. Observation on June 11, 2019, at 11:30 AM revealed the building separation doors near Room 219 and the Main Dining Rooms had the labels painted over, and were not able to verify the ratings of these doors.

Interview with Maintenance Director on June 11, 2019, at 11:30 AM confirmed the labels of the common wall rated doors were painted over.



 Plan of Correction - To be completed: 07/19/2019

Preparation, submission and implementation of this plan of correction does not constitute an admission of agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continuously improve the quality of care and to comply with all state and federal regulatory requirements.

- Paint was removed from labels to reveal fire rating.
- Company was called to re-inspect doors and install new labels.
- Maintenance was in serviced on not painting labels.
- Maintenance Director or designee will audit fire-rating areas monthly to ensure the fire ratings remain visible. These audits will be reviewed at QAPI.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
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 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the chute terminus door to be unobstructed from closing, in one of one room within the component.

Findings include:

1. Observation on June 11, 2019, at 11:45 AM revealed the chute terminus door was being held open by a wooden piece of wood, instead of the fusible link, or an acceptable hold-open device.

Interview with Maintenance Director on June 11, 2019, at 11:45 AM confirmed the chute terminus door was held open with a piece of wood.




 Plan of Correction - To be completed: 07/19/2019

- Wood blocking was removed from door.
- Company is coming in to install new fusible link.
- Maintenance and Laundry Personal was in serviced on proper operation of door.
- Housekeeping Director or designee will audit Laundry door to ensure proper operation monthly. These audits will be reviewed at QAPI.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
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, facility failed to conduct the rated door inspection, in two of two components.

Findings include:

1. Review of documentation on June 11, 2019, at 8:50 AM revealed the facility did not conduct the annual rated door inspection. Last inspection was May 21, 2018.

Interview with Maintenance Director on June 11, 2019, at 8:50 AM confirmed the annual inspection of rated doors was not conducted.




 Plan of Correction - To be completed: 07/19/2019

- Fire Door inspection was completed.
- Doors will be inspected semi-annually so all are completed within year.
- Maintenance was inserviced on door inspections.
- Maintenance Director or designee will review door inspection semi-annually at the QAPI.

Initial comments:Name: NEW BUILDING - Component: 02 - Tag: 0000


Facility ID# 022202
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2019, it was determined that The Gardens at Blue Ridge 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 one-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: NEW BUILDING - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the hazardous area doors to positively latch, in one of two components.

Finding include:

1. Based on observation on June 11, 2019, at 10:30 AM revealed the Mechanical Boiler Room doors were both taped open to prevent the latching mechanism to be unable to work.

Interview on June 11, 2019, at 10:30 AM with the Maintenance Director confirmed the doors to the Mechanical Boiler Room failed to positively latch.



 Plan of Correction - To be completed: 07/19/2019

- Tape was removed from doors and latching was changed
- Other doors were checked for any items that affected latching.
- Maintenance was in-services on proper operation of door latching.
- Maintenance Director or designee will audit door latching monthly. These audits will be reviewed at QAPI.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
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: NEW BUILDING - Component: 02 - Tag: 0761

Based on document review and interview facility failed to conduct the rated door inspection in two of two components.

Findings include:

1. Review of documentation on June 11, 2019, at 8:50 AM revealed the facility did not conduct the annual rated door inspection. Last inspection was May 21, 2018.

Interview with Maintenance Director on June 11, 2019, at 8:50 AM confirmed the annual inspection of rated doors was not conducted.



 Plan of Correction - To be completed: 07/19/2019

- Fire Door inspection was completed.
- Doors will be inspected semi-annually so all are completed within year.
- Maintenance was inserviced on door inspections.
- Maintenance Director or designee will review door inspection semi-annually at the QAPI.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port