Pennsylvania Department of Health
GROVE AT GREENVILLE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GROVE AT GREENVILLE, 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 July 24, 2024, at The Grove at Greenville, 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 # 070402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 24, 2024, it was determined that The Grove at Greenville 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 V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress Doors:

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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, the facility failed to maintain the means of egress, to be free of obstructions, on one of two building levels.

Findings include:

Observation on July 24, 2024, at 9:04 a.m., revealed the first floor, Alzheimer unit, kitchen storage room door was configured with a padlock.

Interview with the maintenance supervisor on July 24, 2024, at 9:04 a.m., confirmed the door could potentially delay egress during an emergency.

Plan of Correction - To be completed: 08/26/2024

1. Padlock will be removed from kitchen storage room door to maintain the means of egress
2. Maintenance supervisor will be re-educated by administrator on the placing of locks on Egress Doors

NFPA 101 STANDARD Exit Signage:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit and directional signage for one of over four emergency exits.

Findings include:

Observation on July 24, 2024, at 9:41 a.m., revealed the corridor near the unit #1 nurse station was missing directional exit signs to the unit #4 exit and the employee breakroom exit.

Interview with the maintenance tech on July 24, 2024, at 9:41 a.m., confirmed the deficiencies at the time of the survey.

Plan of Correction - To be completed: 08/26/2024

1. the Maintenance Supervisor/or designee will be responsible to inspect means of egress in the facility daily.
2. Directional exit signs will be installed near unit #1 nurse station to the unit #4 exit and the employee breakroom exit.

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, the facility failed to maintain inspection and testing for one of two kitchen exhaust hoods.

Findings include:

Document review on July 24, 2024, at 8:56 a.m., revealed the facility was unable to provide documentation for the most-recent semi-annual kitchen exhaust hood cleaning. The last documented hood clearning occurred on August 2, 2023.

Interview with the maintenance supervisor on July 24, 2024, at 8:56 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 08/26/2024

Administrator will work with Mongiovi and Son to request and obtain report regarding semi-annual hood cleaning to show facility compliance.

Maintenance Director and NHA will obtain reports detailing compliance immediately after services are performed.

Maintenance Director will monitor deficiencies quarterly, and report any non-compliance to Quality Assurance team.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):

Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, the facility failed to maintain alcohol-based hand rub dispensers on one of two building levels.

Findings include:

Observation on July 24, 2024, at 10:30 a.m., revealed the facility had alcohol-based hand rub dispensers mounted directly above electrical outlets/devices throughout the first floor.

Interview with the maintenance supervisor on July 24, 2024, at 10:30 a.m., confirmed the hand rub dispenser deficiencies.

Plan of Correction - To be completed: 08/26/2024

Alcohol based hand rub dispensers mentioned will be removed from being directly above electrical outlets/devices.

Facility-wide audit will be performed to ensure there are no other hand rub dispensers above any electrical outlets/devices

Maintenance Supervisor/designee will be responsible to inspect hand-rub dispensers and report any non-compliance to Quality Assurance team.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to maintain the inspection and testing of one of one fire alarm system.

Findings include:

Document review on July 24, 2024, at 9:10 a.m., revealed the inspection that occurred on September 5, 2023, noted that the fire alarm system did not have an elevator recall programmed into the system.

Interview with the maintenance supervisor on July 24, 2024, at 9:10 a.m., confirmed the facility was unable to provide corrective documentation of the deficiency at the time of the survey.

Plan of Correction - To be completed: 08/26/2024

Facility has tentative appointment scheduled with Eastern Elevator between August 14th and August 16th.

Elevator recall program deficiency will be corrected.

Facility will be in compliance.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, the facility failed to maintain inspection and testing for two of two sprinkler systems.

Findings include:

Document review on July 24, 2024, between 8:47 a.m. and 8:50 a.m., revealed the facility was unable to provide documentation for the following sprinkler system maintance requirements:
A. (8:47 a.m.) Quarterly reports, April 23, 2024 and January 30, 2024, noted deficiencies reported during the last inspection were not corrected, with no additional information or corrective documentation available;
B. (8:50 a.m.) Five-year gauge recalibration or replacement;
C. (8:50 a.m.) Five-year internal pipe inspection.

Interview with the maintenance supervisor on July 24, 2024, at 8:50 a.m., confirmed the facility was unable to provide the documentation.

Plan of Correction - To be completed: 08/26/2024

Facility to coordinate with Mongiovi and Son and have made available report which includes quarterly reports, the five-year gauge recalibration, and five year internal pipe inspection.

Facility will ensure inspections continue to be performed quarterly with documentation of any corrected deficiencies.

Maintenance Director and NHA will obtain reports detailing compliance immediately after services are performed.

Maintenance Director will monitor deficiencies for ongoing compliance monthly.

NFPA 101 STANDARD Corridor - Doors:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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, the facility failed to ensure corridor doors would resist the passage of smoke in one of approximately 100 rooms within the facility.

Findings include:

Observation on July 24, 2024, at 8:50 a.m., revealed the first floor resident room 227 door failed to positively latch in the frame.

Interview with the maintenance supervisor on July 24, 2024, at 8:50 a.m., confirmed the door failed to positively latch.

Plan of Correction - To be completed: 08/26/2024

Maintenance department to replace broken door latch with functional door latch and ensure proper functioning

Maintenance department will ensure all resident room doors positive latch function is working properly.

Maintenance department will continue to monitor for deficiencies and Safety Committee will review repairs to ensure corrections are properly made.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, the facility failed to maintain door inspection and testing requirements for one of one component.

Findings include:

Document review on July 24, 2024, at 8:45 a.m., revealed the fire door inspection lacked a date indicating when the inspection occurred.

Interview with the maintenance supervisor on July 24, 2024, at 8:45 a.m., confirmed the facility was unable to provide the inspection date at the time of the survey.

Plan of Correction - To be completed: 08/26/2024

Fire door inspection will continue to be performed routinely in maintenance supervisor/designee job responsibilities.

All fire door inspection testing will be logged and maintained by maintenance director to show facility compliance.

Maintenance Director will be responsible for monitoring deficiencies for ongoing compliance.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in one of three boiler rooms.

Findings include:

Observation on July 24, 2024, at 9:18 a.m., revealed the boiler room behind the kitchen had a breaker box missing the cover, exposing wires.

Reference: NFPA 70-406.6

Interview with the maintenance supervisor on July 24, 2024, at 9:18 a.m., confirmed the electrical system deficiency.

Plan of Correction - To be completed: 08/26/2024

A cover to go over the breaker box panel will be installed to prevent wire exposure and maintain safety.

Maintenance Department will inspect breaker-box quarterly to determine if there are any deficiencies and make corrections if applicable.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on document review and interview, the facility failed to maintain receptacle inspection and testing requirements throughout one of one component.

Findings include:

Document review on July 24, 2024, at 9:22 a.m., revealed the facility was replacing hospital grade receptacles. The facility failed to provide annual testing for all non-hospital grade receptacles.

Interview with the maintenance supervisor on July 24, 2024, at 9:22 a.m., confirmed the facility was unable to provide a date for the documentation at the time of the survey.

Plan of Correction - To be completed: 08/26/2024

The maintenance staff will be in-serviced on Electrical System receptacles.

The Maintenance staff/designee will audit for any receptacles non-hospital grade per code requirements and will make audit available for life safety inspector at the time of revisit. Maintenance Director will report any concerns to the Quality Assurance Performance improvement committee.

These checks will be completed monthly by maintenance department, Safety Committee will review the repair to ensure all corrections are made

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 document review and interview, the facility failed to maintain inspection and testing requirements for one of one essential electrical system.

Findings include:

Document review on July 24, 2024, at 9:40 a.m., revealed the facility was unable to provide documentation for the annual 90-minute load bank test.

Interview with the maintenance supervisor on July 24, 2024, at 9:40 a.m., confirmed the facility was unable to provide a date for the documentation at the time of the survey.

Plan of Correction - To be completed: 08/26/2024

Generator report will be obtained from Curtis Power Solutions and show facility compliance.

Maintenance Director will obtain reports detailing compliance immediately after services are performed.

Maintenance Director will monitor deficiencies quarterly, and report any non-compliance to Quality Assurance team.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cords in one of more than three smoke compartments.

Findings include:

Observation on July 24, 2024, at 8:32 a.m., revealed the therapy room had a coffee pot plugged into a surge protector.

Interview with the maintenance supervisor on July 24, 2024, at 8:32 a.m., confirmed the power cord deficiency.

Plan of Correction - To be completed: 08/26/2024

The surge protector observed in the therapy gym will be unplugged and removed to allow facility to comply with NFPA 101.

Therapy department will be educated and in-serviced by Maintenance Director to ensure facility compliance.

Maintenance Department will continue to sweep facility to ensure power cords are not being used in facility.

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