Pennsylvania Department of Health
 WESTMINSTER WOODS AT HUNTINGDON
Building Inspection Results

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WESTMINSTER WOODS AT HUNTINGDON
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

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WESTMINSTER WOODS AT HUNTINGDON - 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 May 15, 2024, at Westminster Woods at Huntingdon, 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# 077502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, it was determined that Westminster Woods at Huntingdon 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 III (211), protected, ordinary building, with a basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Vertical Openings - 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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in one instance, affecting two of six smoke compartments.

Findings include:

1. Observation on May 15, 2024, at 10:12 a.m., revealed two unsealed pipe penetrations above the heating unit inside stairway number one on the ground floor.

Interview with the Facility Administrator and the Maintenance Supervisor on May 15, 2024, at 1:30 p.m., confirmed the listed vertical opening enclosure deficiency.


 Plan of Correction - To be completed: 06/26/2024

Unsealed pipe penetrations inside stairway number one were sealed with a UL approved through penetration fire stop system.

Other facility stairways were inspected to verify no unsealed pipe penetrations.

Education provided to the maintenance team pertaining to openings between floors are enclosed with construction having a fire resistance rating. Repairs will be inspected by Maintenance Supervisor and/or designee to ensure proper fire rated materials are utilized.

Random observations will be completed by Environment Service Director and/or designee 1x monthly for 3 months . The monitoring results will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.

NFPA 101 STANDARD Cooking Facilities: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.
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 documentation review, observation, and interview, it was determined the facility failed to maintain the kitchen hood in one instance, affecting one of six smoke compartments.

Findings include:

1. Document review and observation on May 15, 2024, at 11:35 a.m., revealed the facility failed to perform one of two required semi-annual kitchen hood cleanings in the past twelve months.


Interview with the Facility Administrator and the Maintenance Supervisor on May 15, 2024, at 1:30 p.m., confirmed the listed kitchen hood cleaning deficiency.




 Plan of Correction - To be completed: 06/26/2024

Dates of semi-annual hood inspection completions are 1/20/24 and 5/15/24.

Education provided to the Environmental Service Director in reference of two required semi-annual kitchen hood cleanings within previous 12-month period.

These inspections will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.

NFPA 101 STANDARD Sprinkler System - Supervisory Signals: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 - Supervisory Signals
Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired.
9.7.2.1, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0352

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility. Testing shall be in accordance with NFPA 72...14.4.5. Number 15 L (1) and (M)

Findings include:

1. Review of documentation on May 15, 2024, at 11:35 a.m., revealed the facility failed to perform the following two required semi-annual inspections of the automatic sprinkler system:

a) valve supervisory switches/tamper switch (semi-annual) 14.4.5, initiating devices (1);
b) vane and pressure switch water flow alarm devices (semi-annual) 14.4.5 initiating devices (m).

Interview with the Facility Administrator and the Maintenance Supervisor on May 15, 2024, at 1:30 p.m., confirmed the missing automatic sprinkler system testing documentation.


 Plan of Correction - To be completed: 06/26/2024

Semi-annual sprinkler inspection completed on 4/4/24 and next scheduled inspection on 6/18/24 to include valve supervisory switches/tamper switch and vane and pressure switch water flow alarm devices.

Facility updated electronic work order management system to include review of semi-annual sprinkler inspections of automatic sprinkler system. Education provided to Environmental Service Director in reference to requirements of semi-annual sprinkler inspection.

These inspections will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.

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, it was determined the facility failed to maintain the automatic sprinkler system in six instances, affecting the entire facility.

Findings include:

1. Observation on May 15, 2024, revealed the following automatic sprinkler system deficiencies:

a) 10:26 a.m., there was an unsealed penetration in the ceiling of the housekeeping/maintenance storage room, above the shelves along the back wall of the room;
b) 10:33 a.m., the facility used an unapproved sealant (fiberglass insulation) to seal pipes in the ceiling of the mechanical room by the generator room entrance door;
c) 10:45 a.m., inspection above the ceiling by the loading dock door on the first floor, revealed there was a sprinkler pipe supported by an unapproved support device (wire);
d) 10:52 a.m., there was a section of ceiling that was not sealed to the front of the walk-in freezer and refrigerator in the kitchen, leaving a large gap in the ceiling;
e) 11:29 a.m., there were multiple misaligned ceiling tiles in front of elevator number four on the first floor, leaving multiple unsealed gaps in the ceiling;
f) 11:35 a.m., a review of documentation revealed the required annual inspection of the fire pump had not been performed in the last 12 months. The most recent inspection of the fire pump was performed on July 7, 2022.

Interview with the Facility Administrator and the Maintenance Supervisor on May 15, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system and fire pump maintenance inspection/testing deficiencies.





 Plan of Correction - To be completed: 06/26/2024

Unsealed penetration in housekeeping/maintenance storage room corrected. Unapproved sealant removed and replaced with approved sealant to seal pipes in ceiling of mechanical room. Unapproved sprinkler support device replaced with approved device above loading dock door. Ceiling sealed to the front of the walk-in freezer and refrigerator in kitchen. Ceiling tiles replaced in front of elevator number four. Fire pump inspection scheduled for 6/18/24.

Education provided to the maintenance team in reference to unsealed penetrations and automatic sprinkler system maintenance. Environmental Service Director educated on required annual inspection of fire pump. Repairs will be inspected by Maintenance Supervisor and/or designee to ensure proper materials are utilized.

Random observations will be completed by Environment Service Director and/or designee 1x monthly for 3 months. These results will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.

NFPA 101 STANDARD Corridor - 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.
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 doors in three instances, affecting two of six smoke compartments.

Findings include:

1. Observation on May 15, 2024, revealed the following resident room doors were warped at the top and side and could not resist the passage of smoke when fully closed and latched in their frame:

a) 11:17 a.m., the door to resident room 301;
b) 11:22 a.m., the door to resident room 402;
c) 11:24 a.m., the door to resident room 406.


Interview with the Facility Administrator and the Maintenance Supervisor on May 15, 2024, at 1:30 p.m., confirmed the listed corridor door deficiencies.




 Plan of Correction - To be completed: 06/26/2024

Resident room door numbers 301, 402 and 406 replaced.

Facility quarterly maintenance door checklist has been updated to include resident door fully closed and latched in their frame. Education provided to the maintenance team in reference to resident door requirements.

Random observations will be completed by Environment Service Director and/or designee 1x monthly for 3 months. These results will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0754

Based on observation and interview, it was determined the facility failed to maintain soiled linen and trash containers in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 15, 2024, at 11:31 a.m., revealed an unattended Shred-it container greater than 32 gallons in size in PT.


Interview with the Facility Administrator and the Maintenance Director on May 15, 2024, at 1:30 p.m., confirmed the listed soiled linen and trash container deficiency.






 Plan of Correction - To be completed: 06/26/2024

Third-Party Recycling container greater than 32 gallons was replaced with secure console.

Other facility Third-Party Recycling containers were checked to verify appropriate size and storage. Education provided to the Maintenance Supervisor pertaining to required size of containers.

Random observations will be completed by Environment Service Director and/or designee 1x monthly for 3 months . The monitoring results will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 automatic transfer switch, in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Findings include:

1. Review of documentation on May 15, 2024, at 11:35 a.m., revealed the facility failed to perform and document the required monthly testing/function of the automatic transfer switch and that a delay of not more than ten seconds shall be permitted to emergency power.


Interview with the Facility Administrator and the Maintenance Supervisor on May 15, 2024, at 1:30 p.m., confirmed the listed automatic transfer switch deficiency.






 Plan of Correction - To be completed: 06/26/2024

Facility weekly generator maintenance checklist updated to include test/function of the automatic transfer switch within the required time.

Education provided to the maintenance team pertaining to the updated checklist and time requirements for the automatic generator transfer switch.

Random observations will be completed by Environment Service Director and/or designee 1x monthly for 3 months . These results will be reported at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.


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