Pennsylvania Department of Health
WAYNE WOODLANDS MANOR
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 36 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.


WAYNE WOODLANDS MANOR - 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 17, 2024, it was determined that Wayne Woodlands Manor was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748, 416.54, 418.113, 441.184, 482.15, 483.475, 483.73, 484.102, 485.542, 485.625, 485.68, 485.727, 485.920, 486.360, 491.12 CONDITION Establishment of the Emergency Program (EP):

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.

§403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12

The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:

* (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.)

*[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

*[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Observations:
Name: - Component: -- - Tag: 0001

Based on documentation review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility.

Findings include:

1. Review of documentation on April 17, 2024, at 12:55 p.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 483.73, to include the following standards:

(a) Emergency Plan
(b) Policies and Procedures
(c) Communication Plan
(d) Training and Testing

Interview with the Facility Administrator on April 17, 2024, at 1:10 p.m., confirmed the facility failed to establish an emergency preparedness plan, required to be in place by November 15, 2017.

Plan of Correction - To be completed: 06/11/2024

The current Disaster plan will be reviewed and will be updated to the Emergency preparedness requirements for 42 CFR 483.73. We will ensure that it is in compliance with federal, state, and local emergency preparedness requirements. The plan will include provisions for 1)Emergency plan, 2) Policies and procedures, 3) communication plan, and 4)Training and testing. The Plan will be reviewed annually the Corporate compliance Committee.

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

Facility ID# 065902
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on April 17, 2024, it was determined that Wayne Woodlands Manor 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 483.70(a).

This is a one story, Type V (111), protected, wood frame building, 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 six locations, affecting one of one floor.

Findings include:

1. Observation on April 17, 2024, between 10:50 a.m., and 11:25 a.m., revealed the following:

a. 10:50 a.m., a speaker, located within the Green Hall, lacked bonnet protection.
b. 10:55 a.m., recessed lighting fixtures, located within the Classroom areas, lacked bonnet protection.
c. 10:59 a.m., recessed lighting fixtures, located within the Peach Dining Room, lacked bonnet protection.
d. 11:03 a.m., a speaker, located at the entrance to Peach Hall, lacked bonnet protection.
e. 11:14 a.m., recessed lighting fixtures, as well as speakers, located within the TV Lounge, lacked bonnet protection.

Exit interview with the Facility Administrator and the Facilities Manager on April 17, 2024, between 1:00 p.m., and 1:10 p.m., confirmed the building construction deficiencies.

Plan of Correction - To be completed: 06/11/2024

A part of our follow up to the damper deficiency, we have brought in the Chief Facilities Officer from our sister organization, Wayne Memorial Hospital, for assistance. He was able to help us determine what we actually have going on in our institution. The ceiling systems in our facility consist of both hard sheetrock and acoustical drop ceilings depending on location in the building.
The previous maintenance personnel had improperly marked 2' x 2' diffusers in the drop ceiling as fire rated. This gave the on-site inspector the illusion that the drop ceiling was the fire barrier to the attic space above. The astute inspector then recognized that the lighting and speakers installed in the drop ceiling lacked the bonneted fire covers, which would invalidate this as a fire barrier. It has since been determined that above the drop ceiling there is in fact a sheetrock fire rated barrier affixed to the bottom side of the wood trusses. In preforming a few checks, we have found the actual fire dampers located in the ductwork at the sheetrock level with the roof trusses. In addition to the dampers in the HVAC system, all of the other suppression, plumbing, and electrical penetrations were all sealed with appropriate fire stopping material. All of previously mentioned observations would indicate there is an appropriate fire barrier installed above our suspended ceiling negating the need for any fire bonnet protection.
In our hard fixed ceiling areas there are fire rated diffusers installed. We believe this is where the confusion has come in with previous employees.
Going forward there is no need for fire blankets of bonnet protection, our facilities issue would be improper testing.
We will immediately begin testing of the all the fire rated dampers, those newly found and existing ones. Dampers will be cleaned, tested in accordance to NFPA80. We propose that this will take approximately 3 months to complete facility wide. This will give us a new point to start the 4 year rotation from.
In addition to damper testing, we will be setting up a routine preventative maintenance inspections of the fire barrier above the suspended ceilings. Our ceiling barrier is at multiple heights and includes some wall sections to complete the overall protection envelope. We routinely have contractors in working above the ceilings, running conduit, cables, etc. We want to ensure there are no issues from this point forward.
Our results will be reported out at our QAPI meetings X6.

NFPA 101 STANDARD Fire Alarm - Control Functions:

Fire Alarm - Control Functions
The fire alarm automatically activates required control functions and is provided with an alternative power supply in accordance with NFPA 72.
18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0344

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system, affecting one of one floor.

Findings include:

1. Observation on April 17, 2024, at 11:40 a.m., revealed the facility lacked annual fire alarm inspection data, semi-annual, visual inspection data, as well as biennial sensitivity testing data of building smoke detection units.

Exit interview with the Facility Administrator and the Facilities Manager on April 17, 2024, between 1:00 p.m., and 1:10 p.m., confirmed the fire alarm deficiencies.

Plan of Correction - To be completed: 06/11/2024

Eastern Time will be at the facility on May 6th and 7th to conduct our scheduled inspection of the fire alarm system. At that time they will also do the required sensitivity testing.
Maintenance Director will be educated on regulations relating to the inspections required of the fire alarm system and where to keep the paperwork so it is accessible for inspection.
Maintenance Director will document on calendar annual inspections.
Administrator/designee will audit each year to ensure fire alarm inspection is completed.
Results will be presented at next QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of one floor.

Findings include:

1. Observation on April 17, 2024, at 11:43 a.m., revealed the facility lacked documentation to support a required, three-year, full flow trip test of the dry, automatic sprinkler system.

Exit interview with the Facility Administrator and the Facilities Manager on April 17, 2024, at 1:10 p.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 06/11/2024

Beach Lake Sprinkler has sent over the paperwork from 6/1/2023 for the 3 year, full flow trip test of the dry, automatic sprinkler system.
Maintenance Director will be educated on regulations relating to the inspections required of the sprinkler system and where to keep the paperwork so it is accessible for inspection.
Maintenance Director will document on calendar the next due date for the next inspection.
The Administrator/designee will review the paperwork from Beach Lake sprinkler to make sure the full flow trip test was done and documented.
Results will be presented at next QAPI meeting.

NFPA 101 STANDARD Corridor - Doors:

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 one location, affecting one of one floor.

Findings include:

1. Observation on April 17, 2024, at 10:40 a.m., revealed the Main Dining Room doors required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on April 17, 2024, at 1:10 p.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 06/11/2024

Doors in the Main Dining Room will be adjusted so that they will fully latch.
Maintenance Staff will be educated on adjusting corridor doors to making sure that the doors are able to latch properly.
Audit will be conducted by Maintenance Director/designee weekly x8 to ensure corridor doors are latching properly.
Results will be reviewed at monthly QAPI.

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 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the generator set, affecting one of one floor.

Findings include:

1. Observation on April 17, 2024, at 11:48 a.m., revealed the facility lacked a required, three year, four hour load test of the generator set.

Exit interview with the Facility Administrator and the Facilities Manager on April 17, 2024, at 1:10 p.m., confirmed the generator set deficiency.

Plan of Correction - To be completed: 06/11/2024

The 4-hour continuous exercise test under load conditions was completed 4/23/2024 by Mechanical Services Company.
Maintenance Director will be educated on the regulation that generator sets are inspected under load conditions for 4 continuous hours every 36 months and where to keep the paperwork so it is accessible for inspection.
Maintenance Director will document on Calendar due date for next 4-hour load test.
Administrator/designee will audit every 36 months to ensure compliance.
Results will be reviewed at next QAPI meeting.

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