Pennsylvania Department of Health
 BUCKINGHAM VALLEY NURSING AND REHABILITATION CENTER
Building Inspection Results

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BUCKINGHAM VALLEY NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  49 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.
BUCKINGHAM VALLEY NURSING AND REHABILITATION CENTER - 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 July 11, 2024, at Buckingham Valley Nursing And Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0000


Facility ID# 023502
Component 01
Main Building, South Wing & Rehab Unit

Based on a Medicare/Medicaid Recertification Survey completed on July 11, 2024, it was determined that Buckingham Valley Rehabilitation And Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 basement, that 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: MAIN BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas, affecting two of seven smoke compartments.

Findings include:

Observations on July 11, 2024, between 10:43 a.m. and 11:13 a.m., revealed the following storage rooms lacked a self-closer:

a. 10:43 a.m., on the first floor, small Dining Room was being used for storage;
b. 11:13 a.m., in the basement, Medical Records Storage.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the lack of self-closers.




 Plan of Correction - To be completed: 08/05/2024

Small Dining Room no longer being used for storage;
Medical Records Storage room now has a self-closer
Maintenance Director/ designee will monitor doors that need self-closers, monthly X 3 and report to the QA committee for review and recommendations.

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0347

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

Findings include:

Document review on July 11, 2024, at 9:00 a.m., revealed the facility could not provide documentation of a battery smoke detector replacement policy.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the lack of documentation.







 Plan of Correction - To be completed: 08/05/2024

Facility implemented policy for battery smoke detector replacement.

Maintenance Director/ designee will monitor policies, monthly X 3 and report to the QA committee for review and recommendations.

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 BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of two levels in the facility.

Findings include:

Observation on July 11, 2024, at 11:06 a.m., revealed in the basement, the sprinklers in the Laundry Room had excessive debris on them.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the excessive debris.




 Plan of Correction - To be completed: 08/05/2024

Debris removed from sprinkler head in the laundry room.
Maintenance Director/ designee will monitor sprinkler heads in the building to ensure there is no debris, monthly X 3 and report to the QA committee for review and recommendations.

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 BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of two levels in the facility.

Findings include:

Observation on July 11, 2024, at 10:36 a.m., revealed on the first floor, above the single door by the Nurses' Station, there was an opening in the smoke barrier.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the opening.




 Plan of Correction - To be completed: 08/05/2024

Barrier above the single door by the Nurses' Station, sealed off using UL stop gap penetrations system
Maintenance Director/ designee will monitor building to ensure there are no openings in the fire barriers, monthly X 3 and report to the QA committee for review and recommendations.

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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors, affecting one of two levels in the facility.

Findings include:

Observation on July 11, 2024, at 10:56 a.m., revealed on the first floor, the smoke barrier door next to resident room 103 was binding on the floor and failed to close.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the door failed to close.




 Plan of Correction - To be completed: 08/05/2024

Smoke barrier door next to resident room 103 closes properly.
Maintenance Director/ designee will monitor building to ensure the smoke barriers are sealed, monthly X 3 and report to the QA committee for review and recommendations.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electrical Code, Section 110.26(A)(1), for electrical equipment, affecting one of two levels in the facility.

Findings include:

Observations on July 11, 2004, between 10:57 a.m. and 11:07 a.m., revealed storage within 3 ft of the electrical panels in the following locations:

a. 10:57 a.m., on the first floor, Electric Room across from resident room 128;
b. 11:07 a.m., in the basement, Laundry.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the improper storage.





 Plan of Correction - To be completed: 08/05/2024

Storage was removed from within 3 feet of Electric panels across from resident room 128, as well as in the basement, Laundry.
Maintenance Director/ designee will monitor building to ensure there is no storage within 3 feet of the electric panel, monthly X 3 and report to the QA committee for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: MAIN BLDG 01 (MAIN BLDG, SOUTH WING, REHAB UNIT) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on July 11, 2024, at 9:00 a.m., revealed the facility could not provide documentation of the following inspections:

a. Weekly inspection of battery voltage;
b. Monthly testing of battery conductance.

Exit interview with the Administrator and the Maintenance Director on July 11, 2024, at 11:30 a.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 08/05/2024

Facility initiated Weekly inspection of battery voltage, Monthly testing of battery conductance. Maintenance Director/ designee will monitor building to ensure that the inspections are being done, monthly X 3 and report to the QA committee for review and recommendations.

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