Nursing Investigation Results -

Pennsylvania Department of Health
CONTINUING CARE AT MARIS GROVE
Building Inspection Results

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CONTINUING CARE AT MARIS GROVE
Inspection Results For:

There are  27 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.
CONTINUING CARE AT MARIS GROVE - 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 March 19, 2019, at Continuing Care At Maris Grove, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0000


Facility ID# 21670201
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on March 19, 2019, it was determined that Continuing Care At Maris Grove 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 three-story, Type II (222), fire resistive construction, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0281
Based on observation and interview, it was determined that the facility failed to ensure continuous illumination of means of egress on one of four floors.

Findings include:

1. Observation on March 19, 2019, at 1:55 pm, revealed that 2nd floor stair tower 2, had a light out.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the burned-out bulb.




 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
stair tower #2 light bulbs out Lightbulbs replaced 3/21/19
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A weekly random audit of the stair towers will be conducted to determine no lightbulbs are out.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff aware of light outages require immediate replacement.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain smoke detectors affecting the entire facility.

Findings include:

1. Document review on March 19, 2019, at 9:00 am, revealed documentation of smoke detector sensitivity testing was unavailable at time of survey.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed smoke detector sensitivity testing was not available at time of survey.





 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Two year Sensitivity report completed on 3/25/19
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A monthly review of required scheduled maintenance will be completed by the maintenance supervisor to determine all required maintenance is scheduled and conducted as required.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff aware of required maintenance scheduling.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.

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: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0353
Based on document review, observation and interview, it was determined the facility failed to maintain sprinkler components, and conduct required inspections affecting the entire facility.

Findings include:

1. Document review March 19, 2019, at 9:15 am, revealed documentation of a required 5-year Obstruction Inspection was unavailable at time of survey.

Interview at the exit conference with the Executive Director and the Director of Physical Plant on March 19, 2019, at 2:45 pm, confirmed the missing documentation.

2. Observation on March 19, 2019, between 1:10 pm and 1:20 pm, revealed sprinklers with buildup of debris in the following locations:

a. 1:10 pm, basement kitchen.
b. 1:20 pm, basement laundry room behind dryers.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the sprinklers with buildup of debris.




 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Waymans sprinkler company is scheduled to perform pipe obstruction test on 4/9/19 .
5 year obstruction test will be added to the sprinkler test and documented as required
Buildup of debris on sprinkler heads in the following locations
a. basement kitchen
maintenance cleaned all sprinkler heads in kitchen completed 3/22/19
b. basement laundry room behind dryers
Maintenance cleaned all sprinkler heads in laundry dryer room completed 3/22/19
Maintenance will perform ongoing monthly routine maintenance inspections on sprinkler heads to ensure that they are clean and free of debris or dust

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A weekly random audit of the stair towers will be conducted to determine no lightbulbs are out.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff aware of light outages require immediate replacement.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.



NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0355
Based on document review and interview, it was determined the facility failed to ensure inspection of portable fire extinguishers were performed by certified personnel, affecting the entire facility.

Findings Include:

1. Document review on March 19, 2019, at 9:30 am., revealed documentation was unavailable verifying entities providing servicing and recharging of portable fire extinguishers had attended required training, and were credentialed.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed verification of portable fire extinguisher training was not available at the time of inspection.



 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Waymans Sprinkler company provided copy of certification in fire extinguisher servicing and recharging for Staff responsible for fire extinguisher inspections at rose Court
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A one time review of required staff certifications from outside vendors will be conducted to ensure credentials present in building.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff certifications from outside vendors are present in building.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0372
Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the smoke barrier walls on one of four levels.

Findings include:

Observation on March 19, 2019, at 1:50 pm, revealed, above the smoke doors by C2 elevator, an unsealed penetration around MC cable.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the unsealed penetration.



 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Maintenance sealed penetration around MC cable using 3M fire Sealant CP 25wb+. This is a one component Fire Rated sealant used for through penetrations around pipes ,ducts, and power cables
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A one time audit of the all smoke barrier walls will be conducted by maintenance to ensure that all penetrations are sealed.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff aware of penetrations that must be sealed.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.


NFPA 101 STANDARD Electrical Systems - Receptacles: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.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0912
Based on observation and interview, the facility failed to maintain electric systems in wet locations on one of four floors.

Findings include:

1. Observation on March 19, 2019, at 2:15 pm, revealed, in 1st floor, Physical Therapy, a hydrocollator was not plugged into a Ground Fault Circuit Interrupter (GFCI) receptacle.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the hydrocollator was not plugged into a GFCI receptacle.



 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Electrician installed GFI outlet for Hydrocolator completed 4/3/19
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A one time environmental audit of all equipments that have water within its function will be conducted to ensure they are plugged into the proper outlets.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with maintenance department will occur by the maintenance supervisor or designee to ensure staff aware of equipments plugged into proper outlets.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0914

Based on documentation review and interview it was determined the facility failed to provide annual receptacle testing at bed locations in one instance within the facility.

Findings include:

1. Document review on March 19, 2019, at 9:40 am, revealed the facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the previous 12 months.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the documentation was unavailable.




 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Maintenance staff will complete testing in identified resident rooms by 5/15/2019

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Maintenance staff will perform annual testing of receptacles in all patient rooms
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Maintenance will perform ongoing testing of receptacles in resident rooms as part of routine maintenance.

How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to provide means of securing oxygen cylinders on one of four levels.

Findings include:

1. Observation on March 19, 2019, at 1:40 pm, revealed, in 2nd floor Nurses station, there was a freestanding "E" sized oxygen cylinder that was not in a secured holder.

Interview at the exit conference with the Director of Nursing and the Facilities Manager on March 19, 2019, at 2:45 pm, confirmed the oxygen cylinder was not secured.



 Plan of Correction - To be completed: 05/15/2019

Responses to the cited deficiencies do not constitute an admission of agreement by the facility of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and/or state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Unsecured oxygen tank on the 2nd floor was secured on 3/19/2019

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A weekly random audit of the second floor nursing neighborhoods will be conducted to determine no oxygen tanks are unsecured.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
100% in service with nursing staff will occur by the DON or designee to ensure nursing staff aware oxygen tanks must be secured at all times.
How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
Monthly random audit for the next 3 months will be conducted. Negative findings will be reported to QA committee. Additional audits to be conducted as needed.


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