Nursing Investigation Results -

Pennsylvania Department of Health
WILLOW TERRACE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOW TERRACE
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

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WILLOW TERRACE - 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 March 19, 2021, at Willow Terrace, 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# 072102
Component 01
Willow Terrace

Based on a Medicare/Medicaid Recertification Survey completed on March 19, 2021, it was determined Willow Terrace was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 six-story, Type II (222), fire resistive building, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain a fire resistive separation between buildings, affecting one of six floors in the facility.

Findings include:

1. Observation on March 19, 2021, at 11:45 a.m., revealed holes, in the fire doors, on the Third Floor, near the Freight Elevator.

Exit Interview with the Administrator and Maintenance Director on March 19, 2021, at 12:30 p.m., confirmed the holes in the fire doors.




 Plan of Correction - To be completed: 05/17/2021

On 5/17/21 the holes on the 3rd floor fire doors by the freight elevator were sealed with like material
Maintenance staff was educated on the importance of sealing any holes or penetrations in fire doors
NHA/designee will conduct monthly radon audits on the importance of maintaining fire doors
Results of these audit will be reviewed/reported to QAPI Committee to determine compliance. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to properly install the sprinkler system, affecting one of three stairwells in the facility.

Findings include:

1. Observation on March 19, 2021, between 11:15 a.m. and 12:05 p.m., revealed sprinklers installed within six feet of each other, in Stair Tower 3.

Exit Interview with the Administrator and Maintenance Director on March 19, 2021, at 12:30 p.m., confirmed the improperly installed sprinklers.




 Plan of Correction - To be completed: 05/17/2021

On 5/17/21 the following sprinkler issue was corrected by Johnson Controls
Maintenance staff was educated on the importance of proper spacing of sprinkler heads
Maintenance Director will perform quarterly audits on maintaining proper spacing of sprinkler heads.
These audits will be reviewed/reported to QAPI Committee to determine compliance .QAPI Committee will determine the need for continuance of audits.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of six floors in the facility.

Findings include:

1. Observation on March 19, 2021, at 12:07 p.m., revealed metal clad wiring laying on a sprinkler pipe, above the ceiling, near the smoke barrier doors, on the Second Floor, near Rm. 203.

Exit Interview with the Administrator and Maintenance Director on March 19, 2021, at 12:30 p.m., confirmed the external load on the sprinkler pipe.




 Plan of Correction - To be completed: 05/17/2021

On 5/17/21 the metal clad wiring was security off the sprinkler pipe, near the smoke door, on the 2nd floor near room #203
Maintenance staff was educated on the importance of not having an electrical line laying on sprinkler pipe.
Quarterly random audits will be performed by Maintenance Director or designee on wire placement near sprinkler pipes
Results of these audit will be reviewed/reported to QAPI Committee to determine compliance. QAPI Committee will determine the need for continued audits.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of six floors within the facility.

Findings include:

1. Observation on March 19, 2021, at 10:50 a.m., revealed the fire extinguisher, on the Fifth Floor, near the Freight Elevator, had not been inspected on a monthly basis since 11/2020.

Exit Interview with the Administrator and Maintenance Director on March 19, 2021, at 12:30 p.m., confirmed the missing monthly inspections.




 Plan of Correction - To be completed: 05/17/2021

On 5/17/21 The 5TH Floor extinguisher near the freight elevator has been inspected
Maintenance staff was educated on the importance off all extinguishers being inspected monthly.
Maintenance director or designee will conduct random monthly audits and results are to be reviewed with QAPI Committee for compliance

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 Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls were free of unsealed penetrations and openings, affecting three of six floors.

Findings include:

1. Observation on March 19, 2021, between 10:30 a.m. and 12:05 p.m., revealed unsealed penetrations and openings in smoke barrier walls, in the following locations:

a. 10:30 a.m., Sixth Floor, open penetration, by data wires, above smoke doors, near Laundry Rm. 655;
b. 10:34 a.m., Sixth Floor, opening above duct above smoke doors, near Linen Chute;
c. 10:40 a.m., Sixth Floor, Dining Room, around data wires;
d. 10:52 a.m., Fifth Floor, open penetration, by a sprinkler pipe, above the South Wing doors, near the elevators;
e. 11:45 a.m., Third Floor, above South Wing doors, near the elevators.
f. 12:05 p.m., Third Floor, smoke barrier incomplete, above the ceiling inside Rm. 328.

Exit Interview with the Administrator and Maintenance Director on March 19, 2021, at 12:30 p.m., confirmed the above deficiencies.




 Plan of Correction - To be completed: 05/17/2021


On 5/17/21 Smoke barrier walls were corrected and sealed with 3M UL approved WL-2002 through wall sealant.
Maintenance staff was educated on maintaining free and unsealed smoke barrier walls
Monthly audits will be done by Maintenance Director or designee
Results of these audit will be reviewed/reported to QAPI Committee to determine compliance. QAPI Committee will determine the need for continued audits.
A. 6TH Floor open penetration, by data wires above smoke doors, near laundry room#655.
B. 6th floor opening above duct above smoke door near linen chute.
C. 6th floor dining room around data wires.
D. 5th floor open penetration, by a sprinkler pipe, above the south side doors, near elevators.
E. 3rd floor above south side doors near elevator.
F. 3rd floor smoke barrier incomplete above ceiling inside ceiling in room# 328

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 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, on one of six floors.

Findings include:

1. Observation on March 19, 2021, at 11:40 a.m., in the Med Gas Room, revealed the Fourth Floor, Oxygen Storage Room door was missing fire rated hardware.

Exit Interview with the Administrator and Maintenance Director on March 19, 2021, at 12:30 p.m., confirmed the missing rated door hardware.




 Plan of Correction - To be completed: 05/17/2021

On 5/17/21 the 4th floor oxygen room door hardware was replaced with fire rated hardware.
Maintenance staff was educated on the importance of fire rated hardware.
Monthly audits will be done by Maintenance Director or designee
Results of these audit will be reviewed/reported to QAPI Committee to determine compliance. QAPI Committee will determine the need for continued audits.


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