Pennsylvania Department of Health
 EMBASSY OF EAST MOUNTAIN
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMBASSY OF EAST MOUNTAIN
Inspection Results For:

There are  44 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.
EMBASSY OF EAST MOUNTAIN - 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, 2024, at The Gardens at East Mountain, 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# 026502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2024, it was determined that The Gardens at East Mountain 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 (111), protected, wood frame building, with an unused attic space, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of one floor.

Findings include:

1. Observation on April 30, 2024, at 10:40 a.m., revealed recessed lighting fixtures, located at the east Nurse's Station, lacked bonnet protection

Exit interview with the Facilities Manager on April 30, 2024, at 11:15 a.m., confirmed the building construction deficiency.



 Plan of Correction - To be completed: 06/01/2024

Bonnet protection will be applied to all recessed lighting fixtures
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 BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of one floor.

Findings include:

1. Observation on April 30, 2024, at 10:07 a.m., revealed the Laundry Folding Room door was held open by unapproved means.

Exit interview with the Facilities Manager on April 30, 2024, at 11:15 a.m., confirmed the hazardous area enclosure deficiency.



 Plan of Correction - To be completed: 06/01/2024

Laundry door was immediately closed.
Housekeeping and Laundry staff re-educated on inappropriately propping the door open by unapproved means.
Random audits will be completed weekly x 4 to ensure Laundry door is not inappropriately propped open with results to QAPI for review and recommendation.

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 BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting one of one floor.

Findings include:

1. Observation on April 30, 2024, at 10:23 a.m., revealed the west smoke barrier separation doors required adjustment to fully latch.

Exit interview with the Facilities Manager on April 30, 2024, at 11:15 a.m., confirmed the smoke barrier separation door deficiency.



 Plan of Correction - To be completed: 06/01/2024

The west smoke barrier door has been adjusted to fully latch.
Random audit of smoke barrier door will be completed to ensure full closure, weekly x4 then monthly with results to QAPI 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, observation, and interview, it was determined the facility failed to install and maintain the heating, ventilation, and air conditioning systems in seven of seven smoke compartments within the facility.

Findings include:

1. Observation and documentation review on April 30, 2024, at 10:00 a.m., revealed corridors and resident rooms throughout this component share return air. Note: supply air is generated from eighteen Borg/Warner, gas-fired heating and air conditioning units.

Exit interview with the Facilities Manager on April 30, 2024, at 11:15 a.m., confirmed the heating, ventilation, and air conditioning deficiency.

A CMS approved permanent waiver was issued for this condition on 11/12/2009.




 Plan of Correction - To be completed: 06/01/2024

Approved waiver form 1/12/2009
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 one location, affecting one of one floor.

Findings include:

1. Observation on April 30, 2024, at 10:02 a.m., revealed discarded cigarettes, located at the exterior loading dock area.

Exit interview with the Facilities Manager on April 30, 2024, at 11:15 a.m., confirmed the smoking regulations deficiency.



 Plan of Correction - To be completed: 06/01/2024

Cigarette butts were immediately cleaned up.
All staff re-educated on allowed smoking areas.
Random audits will be completed to ensure smoking regulations are followed weekly x4 with results to QAPI for review and recommendation.


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: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of one floor.

Findings include:

1. Observation on April 30, 2024, at 10:12 a.m., revealed an unsecured oxygen cylinder, located at the west Nurse's Station.

Exit interview with the Facilities Manager on April 30, 2024, at 11:15 a.m., confirmed the oxygen cylinder storage deficiency.



 Plan of Correction - To be completed: 06/01/2024

O2 cylinder was immediately secured Licensed staff re-educated on appropriate storage of o2 cylinders.
random weekly audits will be completed to ebsure proper O2 cylinder storage weekly X4 with results to QAPI for review and recommendation.

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