Nursing Investigation Results -

Pennsylvania Department of Health
GLEN AT WILLOW VALLEY, THE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GLEN AT WILLOW VALLEY, THE
Inspection Results For:

There are  48 surveys for this facility. Please select a date to view the survey results.

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GLEN AT WILLOW VALLEY, 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 February 19, 2020, at The Glen at Willow Valley, 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 #077902
Component 01
The Glen

Based on a Medicare/Medicaid Recertification Survey completed on February 19, 2020, it was determined that The Glen at Willow Valley 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 six-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, and the rating of the common walls, on one of six floors within the component.

Findings include:

1. Observation on February 19, 2020, between 12:45 PM and 1:45 PM, revealed common wall doors exceeded the maximum allowed gap margins, at the following locations:

a. 12:45 PM, 3rd floor, separating the Glen and the Manor;
b. 1:05 PM, 3rd floor, separating the Glen and the 1st floor North;
c. 1:45 PM, 3rd floor, Main Kitchen Office fire door.

Interview with the Manager of Environmental Services on February 19, 2020, at 1:45 PM confirmed the common wall doors exceeded the allowed gap margins.


2. Observation on February 19, 2020, at 1:05 PM revealed penetration of the common wall separating the 3rd floor Glen and the 1st floor North, above the common wall doors, around blue and white data wires.

Interview with the Manager of Environmental Services on February 19, 2020, at 1:05 PM confirmed there was a penetration.



 Plan of Correction - To be completed: 02/22/2020

1. a.,b., the common wall doors at the the 3rd floor separating the Glen and the Manor, and the Glen and the 1st floor North, are both metal doors and will be adjusted as to not exceed the maximum allowed gap margins of 3/16th inch gap.
c. The Main Kitchen Office fire door is wood and will be adjusted as not to exceed the maximum allowed gap margins of 1/8th inch.

The Maintenance Director/designee will conduct monthly door inspections scheduled per the Maintenance TMS system. Any door noted to have a gap greater than the allowable gap margins between the door and the door frame will be adjusted or replaced as needed.
Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

2. The penetration of the common wall separating the 3rd floor Glen and the 1st floor North, above the common wall doors, around blue and white data wires was sealed with an approved through penetration fire stop system to seal the penetrations. The facility will maintain the rating of the common walls.

Maintenance Director/designee will send a communication to the IT, Renovations, Maintenance and related Construction Managers to inspect the work of contractors to make sure all penetration of fire walls are sealed with rated fire caulking and not sign off on the job until the work has been inspected and is complete.

The Maintenance Director/designee will conduct random monthly inspections of penetrations of common walls scheduled per the Maintenance TMS system.

Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, affecting three of six stairtowers within the component.

Findings include:

1. Observation on February 19, 2020, between 12:50 PM and 2:00 PM, revealed stairtower doors exceeded the allowed gap margins, at the following locations:

a. 12:50 PM, 3rd floor, HC-4 stairtower door, by the Resident Room 319;
b. 1:00 PM, 3rd floor, HC-3 stairtower door, by the hour separation of the 3rd floor Glen to the 1st floor North Building;
c. 2:00 PM, 2nd floor, HC-1 stairtower door, by the Beauty Shop.

Interview with the Manager of Environmental Services on February 19, 2020, at 2:00 PM confirmed stairtower doors exceeded the allowed gap marings.





 Plan of Correction - To be completed: 04/15/2020

1. a. The wood doors located at the stair tower on the 3rd floor, HC-4 by resident Room 319; b. 3rd floor, HC-3 stair tower by the hour separation of the 3rd floor Glen to the 1st floor North Building; and, c. 2nd floor, HC-1 stair tower door by, the Beauty Shop will be adjusted as not to exceed the maximum allowed gap margin of 1/8th inch.
The Maintenance Director/designee will conduct monthly door inspections scheduled per the Maintenance TMS system. Any wood door noted to have a gap greater than 1/8th inch between the door and the door frame will be adjusted or replaced as needed per regulation.
Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain fire alarm notification devices, affecting one of approximately 30 smoke detectors inspected within the component.

Findings include:

1. Observation on February 19, 2020, at 12:50 PM revealed a dust cover installed on the smoke detector, within the 5th floor Housekeeping Closet C520.

Interview with the Maintenance Supervisor on February 19, 2020, at 12:50 PM confirmed the dust cover had not been removed from the smoke detector.



 Plan of Correction - To be completed: 02/19/2020

A dust cover installed on a smoke detector within the 5th floor Housekeeping Closet C520 was removed at the time of survey.

The Maintenance Director/designee will conduct monthly random inspections to monitor that dust covers are removed from smoke detectors.

Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

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 signage identifying fire extinguishers, within kitchen areas, as a secondary means of extinguishment, affecting two of six floors within the component.

Findings include:

1. Observation on February 19, 2020, between 1:01 PM and 2:35 PM revealed K-type fire extinguishers, at the following locations, lacked signage identifying them as a secondary means of extinguishment:

a) 1:01 PM, 5th floor Country Kitchen;
b) 2:35 PM, 4th floor Country Kitchen.

Interview with the Maintenance Supervisor at 2:35 PM confirmed the lack of identifying signage.



 Plan of Correction - To be completed: 03/05/2020

K-type fire extinguishers located at the both the a. 4th floor, and b. 5th floor Country Kitchens, had signage mounted above both of the K-type fire extinguishers identifying them as a secondary means of extinguishment.

The Maintenance Director/designee will conduct monthly fire extinguishers inspections scheduled per the Maintenance TMS system. Any K-type fire extinguishers not having signage will have the signage added identifying them as a secondary means of extinguishment as required.

Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

NFPA 101 STANDARD Corridor - Doors: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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance and unobstructed closing of corridor doors, affecting three of approximately 200 corridor doors inspected within the component.

Findings include:

1. Observation on February 19, 2020, at 12:00 PM revealed the double closet doors, in the 3rd floor Activities Room, had a gap, greater than 1/8 inch, between the meeting edge.

Interview with the Manager of Environmental Services on February 19, 2020, at 12:00 PM confirmed the large gap.

2. Observation on February 19, 2020, at 1:31 PM revealed the door, to Resident Room 523, was obstructed from closing, by dry cleaning suspended from the door handle.

Interview with the Maintenance Supervisor on February 19, 2020, at 1:31 PM confirmed the door was obstructed from closing and latching within the frame.




 Plan of Correction - To be completed: 04/17/2020

1. The double wood closet doors in the 3rd floor Activities room will adjusted so that the gap is less than 1/8th inch
between the meeting edge of the door.

The Maintenance Director/designee will conduct monthly door inspections scheduled per the Maintenance TMS system. Any door noted to have a gap greater than 1/8th inch at the meeting edge of the door will be adjusted or replaced as needed.

Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

2. The Dry Cleaning suspended from the door of Resident Room 523 was removed the day of survey, February 19, 2020.
The Dry Cleaning Company will be notified not to place dry cleaning on the door handles when returning the residents dry cleaning. Team Members will be educated to not to allow anything to be hung on the residents door handles as to impede door closure and latching within the frame.

The administrator/designee will conduct random monthly audits to ensure nothing is hanging on resident room door handles.

Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters.

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 the rating of smoke barrier walls, affecting one of six floors within the component.

Findings include:

1. Observation on February 19, 2020, at 1:53 PM revealed an unprotected penetration of the smoke barrier wall, within 5th floor Dining Room N5001, located above the suspended ceiling, above a wall-mounted lighting fixture.

Interview with the Maintenance Supervisor on February 19, 2020, at 1:53 PM confirmed the unprotected penetration.




 Plan of Correction - To be completed: 04/17/2020

The penetration of the smoke barrier wall within the 5th floor Dining Room N5001 located above the suspended ceiling, above a wall mounted lighting will be sealed with an approved through penetration fire stop system to seal the penetrations. The facility will maintain the rating of the common walls.

The Maintenance Director/designee will communicate to the IT, Renovations, Maintenance and related Construction Managers to inspect the work of contractors to make sure all penetration of fire walls are sealed with rated fire caulking and not sign off on the job until the work has been inspected and is complete.

The Maintenance Director/designee will conduct random monthly inspections scheduled per the Maintenance TMS system

Areas of noncompliance and corrective actions will be reported to the Quality Assurance Committee on a quarterly basis for two quarters


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