Nursing Investigation Results -

Pennsylvania Department of Health
SWEDEN VALLEY MANOR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SWEDEN VALLEY MANOR
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

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SWEDEN VALLEY MANOR - 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 4, 2019, at Sweden Valley Manor, 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# 455402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 04, 2019, it was determined that Sweden Valley Manor, 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 V (000), unprotected, wood frame building, with a partial basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of seven smoke compartments.

Findings include:

1. Observation on March 4, 2019, at 8:50 a.m., revealed various wires were affixed to branch sprinkler piping within the B Wing attic.

Exit interview with the facility administrator and regional facilities manager on March 4, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the automatic sprinkler system deficiency.




 Plan of Correction - To be completed: 03/29/2019

Various wires that were affixed to branch sprinkler piping within the B Wing attic were fixed so that the wires are no longer affixed to the sprinkler piping

An audit was performed to ensure that no other wires throughout the attic were affixed to the Sprinkler piping.

An audit will be performed weekly for 3 months to ensure various wires will not be affixed to the branch sprinkler piping within the B attic

Audits will be brought to monthly QA meeting for 3 months to ensure audits are being performed.

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 one corridor opening, affecting one of seven smoke compartments.

Findings include:

1. Observation on March 4, 2019, at 8:22 a.m., revealed the Dietary entrance door, lacked smoke-tight integrity.

Exit interview with the facility administrator and regional facilities manager on March 4, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 03/29/2019

Dietary entrance door fixed to ensure smoke-tight integrity



An audit was performed on Dietary entrance door to ensure smoke-tight integrity



An audit will be performed weekly for 3 months on the Dietary entrance door to ensure smoke-tight integrity.


Audits will be reviewed at the monthly QA meeting for 3 months to ensure compliance

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: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting two of seven smoke compartments.

Findings include:

1. Observation on March 4, 2019, at 8:45 a.m., revealed a penetration of the smoke barrier separation wall located within the B Wing attic.

Exit interview with the facility administrator and regional facilities manager on March 4, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the smoke barrier separation wall deficiency.



 Plan of Correction - To be completed: 03/29/2019

Smoke barrier separation wall fixed to ensure there is no penetration within the B wing Attic

Smoke barrier separation wall fixed using fire retardant caulk to ensure there is no penetration of the separation wall.

An audit will be performed weekly for 3 months to ensure there is no penetration of the smoke barrier separation wall within the B attic

Audits will be reviewed at the monthly QA meeting for 3 months to ensure compliance

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in two locations, affecting one of seven smoke compartments.

Findings include:

1. Observation on March 4, 2019, between 8:11 a.m. and 8:18 a.m., revealed the following:
a. 8:11 a.m., discarded cigarette butts were located at the rear exit discharge door.
b. 8:18 a.m., discarded cigarette butts were located at the outdoor resident smoking area.

Exit interview with the facility administrator and regional facilities manager on March 4, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the smoking regulations deficiencies.



 Plan of Correction - To be completed: 03/29/2019

All discarded cigarettes located at the rear exit discharge door and the outdoor resident smoking area were removed and the areas were cleaned appropriately


An in-service was conducted with staff to ensure cigarette butts are properly disposed of in employee and resident smoking areas


An audit will be performed 3x's weekly for 3 months to ensure areas remain clean


Audits to be reviewed during monthly QA meetings for 3 months to ensure compliance

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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 - 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: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain the generator set.

Findings include:

1. Observation on March 4, 2019, at 10:40 a.m., revealed the facility lacked documentation to support required weekly, battery voltage readings/recordings.

Exit interview with the facility administrator and regional facilities manager on March 4, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the generator set deficiency.



 Plan of Correction - To be completed: 03/29/2019

Generator immediately tested and documentation was made to support required weekly, battery voltage readings/recordings.

An in-service from the Administrator to the Environmental Services Supervisor was performed to ensure proper documentation to support required weekly, battery voltage readings/recordings

An audit will be performed weekly with Administrator and Environmental Services Supervisor for 3 months to ensure proper documentation of the required weekly, battery voltage readings/recordings


Audits will be reviewed during monthly QA meetings for 3 months to ensure compliance


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