Pennsylvania Department of Health
FAIRLANE GARDENS NURSING AND REHAB AT READING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FAIRLANE GARDENS NURSING AND REHAB AT READING - 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 22, 2024, at Fairlane Gardens Nursing and Rehab at Reading, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #026202Component 01Main Building
Based on a Medicare/Medicaid Recertification Survey completed on July 22, 2024, it was determined that Fairlane Gardens Nursing and Rehab at Reading 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 structure, with an attic, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on July 22, 2024, between 10:00 AM and 11:30 AM, revealed the facility portable life safety drawings lacked resident room capacities, hazardous areas, travel distance from the furthest point in the zone to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, length & width of zone and labeled use of spaces. The listed information is required to conduct the FSES survey.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed portable life safety drawings of the facility lacked information required by the FSES.

Plan of Correction - To be completed: 09/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because the provisions of state and Federal law require it.

1. Facility updated facility floor plan to reflect facility portable life safety with resident's room capacities, hazardous areas, travel distance from the furthest point in the one to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, length and width of zone and labeled use of space.
2. The Maintenance director or designer will update the floor plan as needed when any changes occur.
3. The Maintenance Director will audit annually floor plans and report findings to the QAPI committee for further action planning.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain the rated horizontal fire doors, to close and latch within the frame, in four of four smoke compartments within the component.
Findings include:
1. Observation on July 22, 2024, between 12:05 PM and 12:53 PM, revealed horizontal fire-rated access doors failed to self-close and latch in the frame, at the following locations:
a. 12:05 PM, by Maintenance Shop;
b. 12:10 PM, by Resident Room 115.
c. 12:15 PM, by Resident Room 303;
d. 12:25 PM, by Resident Room 215;
e. 12:53 PM, by Commercial Laundry Room.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the horizontal fire-rated access doors would not self-close and latch.

Plan of Correction - To be completed: 09/11/2024

1. Facilities horizontal fire-rated access doors are rendering door as non-rated.
2. The Maintenance Director/ Designee will audit semi/annual access doors to ensure the doors meet code.
3. Maintenance Director/designee will report findings to the QAPI Committee for further action planning.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain battery-powered emergency lighting sources, affecting the entire component.

Findings include:

1. Review of documentation and interview on July 22, 2024, at 10:40 AM, revealed the facility failed to perform monthly and annual testing of battery powered emergency lighting sources.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the facility failed to perform the monthly and annual testing for emergency battery operated lights.

Plan of Correction - To be completed: 09/11/2024

1. The Maintenance director did an immediate inspection of the battery powered emergency lighting source.
2. The Maintenance director will perform monthly testing of battery powered emergency lighting sources.
3. The Maintenance Director will audit the battery power monthly to ensure positive lighting source and report findings to the QAPI Committee for further action planning.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide the 3-year sprinkler maintenance documentation, to repair noted deficiencies on the annual report, and to keep sprinkler heads free of debris, which serves the entire component.

Findings include:

1. Review of documentation and interview on July 22, 2024, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation for the 3-year full trip test, for the dry system.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the facility lacked the dry system's 3-year full trip test.

2. Review of documentation and interview on July 22, 2024, between 10:15 AM and 10:18 AM, revealed the following deficiencies for the sprinkler system were found by Berkshire Systems Group on September 6, 2023, annual inspection report, but were not addressed:

a. 10: 15 AM, approximately 50 corroded heads, 1/2 pendant;
b. 10:18 AM, no hydraulic nameplate present.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the sprinkler deficiencies were not completed or addressed.

3. Observation on July 22, 2024, at 12:50 PM, revealed the Laundry Dryer Chase sprinkler head was covered with debris.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the sprinkler head was covered with debris.

Plan of Correction - To be completed: 09/11/2024

1. The documentation for the (3) year full trip test for the dry system was held on 9/20/2022 and documentation is in the life safety book for review.
2. Berkshire Systems Group is scheduled to address the 50 corroded heads,1/2 pendant and no hydraulic nameplate on 9/15/2024.
3. The Maintenance director immediately cleaned the laundry dryer chase sprinkler head covered with debris.
4. The Maintenance director/designee will audit all monthly sprinkler system and sprinkler head documentations.
5. The Maintenance Director will report all findings to QAPI Committee for further action planning.

NFPA 101 STANDARD Portable Fire Extinguishers:

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: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide a certificate for the Fire Extinguisher Technician, affecting the entire component.

Findings include:

1. Review of documentation on July 9, 2024, between 8:30 AM and 10:30 AM, revealed the facility lacked documentation of the annual inspection being completed by a Certified Fire Extinguisher Inspector.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the facility could not provide a certification for Fire Extinguisher Inspector.

Plan of Correction - To be completed: 09/11/2024

1. The certificate was in the book and does not expire
2. The maintenance director or designer will audit semiannually the certifications for vendors and report findings to the QAPI committee for further action planning.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments with a travel distance of 200 feet or less to the smoke barrier doors, throughout the component.

Findings include:

1. Observation on July 22, 2024, from 10:30 AM to 2:00 PM, revealed Zone 1 smoke compartment had a travel distance greater than 200 linear feet.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed Zone 1 smoke compartment had a travel distance greater than 200 linear feet.

Plan of Correction - To be completed: 09/11/2024

1. The facility would like to request an FSES survey. The facility has engaged on architect to resolve the smoke compartment travel distance.
2. Facility is requesting DOH to do FSES.

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 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility lacked ashtrays of noncombustible material and metal container with self-closing device, affecting the entire component.
Findings include:
1. Observation on July 22, 2024, between 12:55 PM and 12:58 PM, revealed designated Smoking Area lacked the following:
a. 12:55 PM, noncombustible ashtray;
b. 12:58 PM, self-closing metal container.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the lack of a required ashtray and containers.

Plan of Correction - To be completed: 09/11/2024

1. The facility ordered a non-combustible ashtray and self-closing metal container.
2. The Maintenance director removed the old cigarette butt receptacle and put the new non-combustible ashtray and self-closing metal container in the designated smoke area.
3. The Maintenance director/designee will audit daily, and clean the designated smoke area and report findings to the QAPI committee for further action planning.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 BUILDING - Component: 01 - Tag: 0918
Based on document review and interview, it was determined the facility failed to provide an annual 90-minute load bank or evidence of the generator carrying a load greater than 30 percent of its name plate rating, which serves the entire component.

Findings include:

1. Review of documentation on July 22, 2024, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation for 90-minute load bank or that the generator carried at least 30 percent of the rated name plate load on each run.

Interview at the time of the exit conference with the Administrator, Director of Nursing and Director of Maintenance on July 22, 2024, at 2:15 PM, confirmed the facility could not provide documentation for the emergency generator annual load bank or that the generator carried at least 30 percent of the rated load.

Plan of Correction - To be completed: 09/11/2024

1. The 90 Minute load bank was completed on 8/18/2023 and valid. The documentation was in the book.
2. The facility is scheduled for is annual 08/2024.

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