Pennsylvania Department of Health
GARDENS AT STEVENS, THE
Building Inspection Results

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GARDENS AT STEVENS, THE
Inspection Results For:

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GARDENS AT STEVENS, 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 January 18, 2024, at The Gardens at Stevens, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: 74 BLDG - Component: 01 - Tag: 0000


Facility ID #041102
Component 01
74 Building

Based on a Medicare/Medicaid Recertification Survey completed on January 18, 2024, it was determined that The Gardens of Stevens 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 two-story, Type II (222), fire resistive structure, without a basement, 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: 74 BLDG - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to positively latch, on one of two floors within the component.

Findings include:

1. Observation on January 18, 2024, at 11:30 AM, revealed the right leaf of the lower-level common wall doors, separating Personal Care from Skilled Nursing, failed to positively latch in the frame.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the common wall door failed to positively latch.



 Plan of Correction - To be completed: 02/23/2024

1. The right leaf of the lower-level common wall doors, separating Personal Care from Skilled Nursing was fixed and will now positively latch in the frame.

2. The corrective action was completed on 2/23/2024

3. The maintenance director or designee will conduct audits of the lower-level common wall doors, separating Personal Care from Skilled Nursing for positive latching into the frame monthly.

4. The results of the audits will be reported monthly to the QAPI Committee for further action if necessary.

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: 74 BLDG - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide annual sprinkler maintenance documentation, 3-year sprinkler maintenance documentation, and the sprinkler piping system, to be free of extraneous weight, affecting the entire component.

Findings include:

1. Review of documentation on January 18, 2024, between 9:25 AM and 9:33 AM, revealed the facility lacked documentation, for the following:

a. 9:25 AM, annual Main Drain/Control Vale Test;
b. 9:25 AM, monthly, 10 minutes run;
c. 9:28 AM, Dry System annual Trip Test and 3-year Full Flow Trip Test;
d. 9:33 AM, annual Fire Pump Inspection.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the lack of documentation for sprinkler system.


2. Observation on January 18, 2024, between 11:33 AM and 11:40 AM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 11:33 AM, lower level, above ceiling, by Director of Rehab Office, various wires;
b. 11:40 AM, lower level, above ceiling, by Nurses' Station 3, insulated pipes and wires.

Interview with the Acting Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed various items laying across sprinkler pipes.




 Plan of Correction - To be completed: 02/23/2024

1. Documentation of the annual Main Drain/Control Vale Test, monthly, 10 minutes run, Dry System annual Trip Test, 3-year Full Flow Trip Test and annual Fire Pump Inspection was obtained and filed by the Maintenance Director.

2. The corrective action was completed on 2/23/2024.

3. The maintenance director or designee will conduct audits of the annual Main Drain/Control Vale Test, monthly, 10 minutes run, Dry System annual Trip Test and 3-year Full Flow Trip Test and annual Fire Pump Inspection quarterly.

4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: 74 BLDG - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on January 18, 2024, between 9:00 AM and 11:00 AM, revealed the facility failed to provide documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the lack of documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months.




 Plan of Correction - To be completed: 02/23/2024

1. Documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months was obtained and filed by the Maintenance Director.

2. The corrective action was completed on 2/23/2024

3. The maintenance director or designee will conduct audits verifying the documentation of emergency diesel fuel reserve had been tested for quality, within the previous twelve months annually.

4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.

Initial comments:Name: 88 BLDG - Component: 02 - Tag: 0000


Facility ID #041102
Component 02
88 Building

Based on a Medicare/Medicaid Recertification Survey completed on January 18, 2024, it was determined that The Gardens of Stevens 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 two-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: 88 BLDG - Component: 02 - Tag: 0324

Based on document review, observation and interview, it was determined the facility failed to provide semi-annual inspections of the chemical fire suppression system for gas cooking, in one of seven smoke zones within the component.

Findings include:

1. Review of documentation and observation on January 18, 2024, between 9:00 AM and 11:00 AM, revealed the kitchen fire suppression system had not been inspected, for the second half of 2023. The last inspection and maintenance was conducted on April 18, 2023.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the facility did not provide a semi-annual inspection.




 Plan of Correction - To be completed: 02/23/2024

1. The kitchen fire suppression system is scheduled to be inspected on 2/9/2024

2. The corrective action will be completed by 2/23/2024.

3. The maintenance director or designee will conduct audits verifying the documentation of kitchen fire suppression system semi-annually.

4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.

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: 88 BLDG - Component: 02 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide annual sprinkler maintenance documentation, 3-year sprinkler maintenance documentation, and the sprinkler piping system, to be free of extraneous weight, affecting the entire component.

Findings include:

1. Review of documentation on January 18, 2024, between 9:25 AM and 9:33 AM, revealed the facility lacked documentation, for the following:

a. 9:25 AM, annual Main Drain/Control Vale Test;
b. 9:25 AM, monthly, 10 minutes run;
c. 9:28 AM, Dry System annual Trip Test and 3-year Full Flow Trip Test;
d. 9:33 AM, annual Fire Pump Inspection.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the facility failed to provide maintenance and testing for the Sprinkler System.




 Plan of Correction - To be completed: 02/23/2024

1. Documentation of the annual Main Drain/Control Vale Test, monthly, 10 minutes run, Dry System annual Trip Test and 3-year Full Flow Trip Test and annual Fire Pump Inspection was obtained and filed by the Maintenance Director.

2. The corrective action was completed on 2/23/2024.

3. The maintenance director or designee will conduct audits of the annual Main Drain/Control Vale Test, monthly, 10 minutes run, Dry System annual Trip Test and 3-year Full Flow Trip Test and annual Fire Pump Inspection quarterly.

4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: 88 BLDG - Component: 02 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on January 18, 2024, between 9:00 AM and 11:00 AM, revealed the facility failed to provide documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the lack of documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months.


 Plan of Correction - To be completed: 02/23/2024

1. Documentation verifying the emergency diesel fuel reserve had been tested for quality, within the previous twelve months was obtained and filed by the Maintenance Director.

2. The corrective action was completed on 2/23/2024.

3. The maintenance director or designee will conduct audits verifying the documentation of emergency diesel fuel reserve had been tested for quality, within the previous twelve months annually.

4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.



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