Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT WYOMING VALLEY, THE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT WYOMING VALLEY, THE
Inspection Results For:

There are  28 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT WYOMING VALLEY, 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 April 30, 2019, at The Gardens at Wyoming Valley, 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# 971402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2019, it was determined that The Gardens at Wyoming Valley, 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 (111), protected, noncombustible building, with rooftop mechanical spaces, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one stair tower enclosure, affecting three of six smoke compartments.

Findings include:

1. Observation on April 30, 2019, at 9:07 a.m., revealed a screw was missing from the third floor portion of the stair tower number three vision panel.

Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the stair tower enclosure deficiency.


 Plan of Correction - To be completed: 05/22/2019

1. The screw from the third-floor stair tower vision panel has been replaced.

2. No other vision panels were effected.

3. The Maintenance Director/Designee will audit the screws 1x/month for 3 months.

4. The results of the audit will be presented to the QA committee for review and recommendation.

NFPA 101 STANDARD Vertical Openings - 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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain one vertical opening, affecting two of six smoke compartments.

Findings include:

1. Observation on April 30, 2019, at 9:09 a.m., revealed a vertical penetration of the floor slab assembly located within the penthouse electrical room.

Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the vertical penetration deficiency.


 Plan of Correction - To be completed: 05/22/2019

1.The vertical penetration of the floor slab assembly in the electrical room has been sealed with NFPA approved caulking.

2.There were no other penetrations in the electrical room

3.The Maintenance Director/Designee will audit the penetration 1x/month for 3 months

4. The results of the audit will be presented to the QA committee for review and recommendation.

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 two locations, affecting two of six smoke compartments.

Findings include:

1. Observation on April 30, 2019, between 9:17 a.m. and 10:03 a.m., revealed the items were stored within eighteen inches of an adjacent sprinkler head assembly in the following locations:

a. 9:17 a.m., third floor clean linen.
b. 10:03 a.m., second floor clean linen.

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


 Plan of Correction - To be completed: 05/22/2019

1.The items in the second and third floor linen closets have been removed to allow 18 inches of space between the sprinkler heads.

2.No other linen closets were affected.
The housekeeping director/designee will in-service the housekeeping staff to insure items in the building are within acceptable ranges from sprinklers.

3.The housekeeping director/designee will audit the linen storage 1x/day for 30 days, then weekly for 4 weeks.

4.The results of the audit will be presented to the QA committee for review and recommendation.


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 corridor openings in five locations, affecting two of six smoke compartments.

Findings include:

1. Observation on April 30, 2019, between 9:12 a.m. and 10:05 a.m., revealed the following:

a. 9:12 a.m., third floor, resident room 325 required adjustment to fully latch within the corresponding door frame assembly.
b. 9:13 a.m., third floor, resident room 324 lacked smoke-tight integrity.
c. 9:21 a.m., third floor, resident room 306 required adjustment to fully latch within the corresponding door frame assembly.
d. 9:59 a.m., second floor, resident room 228 required adjustment to fully latch within the corresponding door frame assembly.
e. 10:05 a.m., the second floor, resident room 209 door was held open by unapproved means (door chock).

Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the corridor opening deficiencies.


 Plan of Correction - To be completed: 05/22/2019

1. Resident rooms 325, 324, 306 and 228 have had their door latches adjusted to fully latch. Room 209 had the door chock removed.
2. There were no other rooms affected.
3. The maintenance director/designee will audit the rooms 325, 324, 306, 228 and 209 to insure the doors positively latch and are not propped open with a door chock weekly for 4 weeks, then monthly for 2 months.
4. The results of the audit will be presented to the QA committee for review and recommendation.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to maintain the heating, ventilation, and air conditioning systems.

Findings include:

1. Observation on April 30, 2019, at 10:50 a.m., revealed the facility lacked documentation to support required, four year, fire and ceiling, fusible link fire damper inspection and testing data.

Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the facility lacked fire and ceiling, fusible link fire damper testing and inspection data.



 Plan of Correction - To be completed: 05/22/2019

1.The maintenance director/designee will perform the fire and ceiling fusible link fire damper inspections.

2.The maintenance director has been in-serviced regarding documentation of fire damper testing and inspection data.

3.The maintenance director will inspect the required number of fire dampers each year.

4.The results of the audit will be presented to the QA committee for review and recommendation.


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

Based on observation and interview, it was determined the facility failed to maintain one laundry chute, affecting three of six smoke compartments.

Findings include:

1. Observation on April 30, 2019, between 10:16 a.m. and 10:18 a.m., revealed the following:

a. 10:16 a.m., the first floor, soiled linen chute termination room door was held open by unapproved means (door chock).
b. 10:18 a.m., penetrations were noted around bar joists within the first floor, soiled linen chute termination room wall (located above the suspended ceiling assembly).

Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the soiled linen chute deficiencies.


 Plan of Correction - To be completed: 05/22/2019

1.The first-floor soiled linen room door had the door chock removed. The penetrations in the soiled utility room have been filled with NFPA approved fire caulk.

2.The housekeeping director/designee will in-service the laundry/housekeeping staff regarding the door chock.

3.The housekeeping director /designee will audit the laundry door daily for 2 months.

4.The results of the audit will be presented to the QA committee for review and recommendation.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to hold fire drills on a random basis.

Findings include:

1. Observation on April 30, 2019, at 10:45 a.m., revealed fire drills were not held on a random basis with respect to days of the month (note: all fire drills were held between the 26th and 30th of the month).

Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the fire drill deficency.


 Plan of Correction - To be completed: 05/22/2019

1.The Fire drills will be held on a random basis in the facility.

2.The Maintenance Director will be in serviced regarding random fire drills.

3.The NHA/designee will audit the fire drills monthly.

4.The results of the audit will be presented to the QA committee for review and recommendation.


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