Pennsylvania Department of Health
GARDENS AT STEVENS, THE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 40 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.


GARDENS AT STEVENS, 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 January 18, 2024, at The Gardens at Stevens, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: 74 BLDG - Component: 01 - Tag: 0000

Facility ID #041102
Component 01
74 Building

Based on a revisit to a Medicare/Medicaid Recertification Survey completed on January 18, 2024, it was determined that The Gardens of Stevens 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 two-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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: 74 BLDG - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide annual sprinkler maintenance documentation, 3 year sprinkler maintenance documentation and sprinkler piping system to be free of extraneous weight affecting the entire component.

Findings include:

1. Document review on January 18, 2024, between 9:00 AM and 11:00 AM, revealed the facility lacked documentation for the following:

a. 9:25 AM, Annual, Main Drain/Control Vale test;
b. 9:28 AM, Dry System, Annual Trip Test and 3-year, Full Flow Trip Test.
c. 9:33 AM Annual Fire Pump inspection;
d. 9:25 AM Monthly, 10 minutes run.

Interview at the time of the exit conference with the Administrator and Maintenance Director on January 18, 2024, at 1:45 PM, confirmed the lack of documentation for sprinkler system.

2. Observation on January 18, 2024, between 11:33 AM and 11:40 AM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 11:33 AM, lower level, above ceiling, by Director of Rehab office, various wires;
b. 11:40 AM, lower level, above ceiling, by Nurses Station 3, insulated pipes, and wires.

Interview with the Acting Administrator and Maintenance Director on January 18, 2024, at 1:45 PM confirmed various items laying across sprinkler pipes.

*******************************

Observation and interview on March 13, 2024, at 11:30 AM, determined items 2a and 2b were not completed.

Interview with the Administrator and Maintenance Director on March 13, 2024, at 11:50 AM, confirmed items 2a and 2b were not completed.

Plan of Correction - To be completed: 03/15/2024

1. The wires resting atop the sprinkler pipe above ceiling, by Director of Rehab office as well as above ceiling, by Nurses Station 3 were moved so as not to rest upon the sprinkler system pipe.

2. The corrective action was completed on 3/15/2024.

3. The maintenance director or designee will conduct audits of the wires above sprinkler pipes to verify they are not resting upon the sprinkler system pipe weekly for 4 weeks and then monthly for 2 months.

4. The results of the audit will be reported monthly to the QAPI Committee for further action if necessary.

Initial comments:Name: 88 BLDG - Component: 02 - Tag: 0000

Facility ID #041102
Component 02
88 Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on January 18, 2024, it was determined that The Gardens of Stevens was in substantial compliance with the 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 two-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement