Pennsylvania Department of Health
COMMUNITIES AT INDIAN HAVEN, THE
Building Inspection Results

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COMMUNITIES AT INDIAN HAVEN, THE
Inspection Results For:

There are  38 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.
COMMUNITIES AT INDIAN HAVEN, 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 March 26, 2024, at The Communities at Indian Haven, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.




 Plan of Correction:


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


Facility ID #090102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 26, 2024, it was determined that The Communities at Indian Haven 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 General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on March 26, 2024, at 9:30 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (2-hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, and designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits shall be clearly noted;
f. Shaft walls.

Interview during the exit conference with the maintenance supervisor on March 26, 2024, at 9:30 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.





 Plan of Correction - To be completed: 04/29/2024

The facility will secure documentation of a portable floor plan for the facility that includes designations of smoke barrier walls (outside wall to outside wall), fire barrier walls, horizontal exits, rated rooms (storage rooms, soiled utility rooms, and designated medical gas rooms) as well as denotation of clearly noted exits and shaft walls. The Environmental Services Director will secure this documentation.

The portable floor plan will be added to the facility's Life Safety manual for future reference and use.

The Nursing Home Administrator or designee will audit weekly for 4 weeks, and monthly for 2 months to assure that the portable floor plan is present and accessible in the facility's Life Safety manual.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 observation and interview, the facility failed to meet fire alarm system testing and maintenance requirements for one of over fifty fire alarm system components.

Findings include:

Observation on March 26, 2024, at 10:20 a.m., revealed the 200 wing exit, located near the nurse station, had a strobe light hanging by the wires.

Interview with the maintenance supervisor on March 26, 2024, at 10:20 a.m., confirmed the the strobe was hanging by the wires, and the issue was fixed on-site.




 Plan of Correction - To be completed: 04/29/2024

The strobe light near the 200 wing exit located near the nurse station was corrected on March 26, 2024 at the time of the observation.

The Environmental Services Director and/or Maintenance Technician will assess remaining strobe lights to assure that the strobe lights are appropriately affixed.

The Environmental Services Director or designee will audit weekly for 4 weeks, and monthly for 2 months to assure that strobe lights are appropriately affixed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, the facility failed to meet sprinkler system maintenance and testing requirements for one of over fifty sprinkler components.

Findings include:

Observation on March 26, 2024, at 11:00 a.m., revealed the activities room, located near room 306, had a sprinkler escutcheon missing at the time of the survey.

Interview with the maintenance supervisor on March 26, 2024, at 11:00 a.m., confirmed the deficiency.



 Plan of Correction - To be completed: 04/29/2024

The sprinkler escutcheon in the activities room, located near room 306, was corrected on March 26, 2024 after this observation.
The Environmental Services Director and/or Maintenance Technician will assess remaining sprinkler escutcheons to assure that the sprinkler escutcheons are in place.
The Environmental Services Director or designee will audit weekly for 4 weeks, and monthly for 2 months to assure that sprinkler escutcheons are in place.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 01 - Component: 01 - Tag: 0355

Based on observation and interview, the facility failed to meet portable fire extinguisher requirements in one of four smoke compartments.

Findings include:

Observation on March 26, 2024, at 9:59 a.m., revealed the mechanical room, located near the 300 wing, had a fire extinguisher stored on the floor, incorrectly mounted.

Interview with the maintenance supervisor on March 26, 2024, at 9:59 a.m., confirmed the extinguisher was not mounted correctly and was being stored behind the door.





 Plan of Correction - To be completed: 04/29/2024

The fire extinguisher located in the mechanical room near the 300 wing was removed from the floor and mounted on the wall on March 26, 2024 after this observation.

The Environmental Services Director and/or Maintenance Technician will assess remaining fire extinguishers to assure that they are correctly mounted.

The Environmental Services Director or designee will audit weekly for 4 weeks, and monthly for 2 months to assure that fire extinguishers are correctly mounted.

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
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, the facility failed to meet soiled linen requirements in one of four smoke compartments.

Findings include:

Observation on March 26, 2024, 10:40 a.m., revealed the 200 wing central bath area, located near the nurse station, next to room 217, had unattended soiled linen stored in the area.

Interview with the maintenance supervisor on March 26, 2024, at 10:40 a.m., confirmed the soiled linen was left unattended.




 Plan of Correction - To be completed: 04/29/2024

The soiled linen in the 200 wing central bath area, located near the nurse station next to room 217 was removed from this area after the observation on March 26, 2024.

The Environmental Services Director and/or Maintenance Technician will assess remaining central bath areas to assure that soiled linen is not stored in these areas.

The Environmental Services Director or designee will audit weekly for 4 weeks, and monthly for 2 months to assure that soiled linen is not stored in central bath areas.

NFPA 101 STANDARD Electrical Systems - Other: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.
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 meet electrical system requirements in one of over four building wings.

Findings include:

Observation on March 26, 2024, between 9:44 a.m. and 9:45 a.m., revealed the facility had storage blocking access to the electrical panels in the following locations:
A. (9:44 a.m.) Central supply had no path or access to four electrical panels in the wheelchair storage room;
B. (9:45 a.m.) Laundry soiled room had storage in front of one electrical panel.

Interview with the maintenance supervisor on March 26, 2024, at 9:45 a.m., confirmed the electric panels were blocked at the time of the survey.



 Plan of Correction - To be completed: 04/29/2024

The four electrical panels in central supply in the wheelchair storage room and one electrical panel in the laundry soiled room were cleared on March 26, 2024 following these observations.

The Environmental Services Director and/or Maintenance Technician will assess electrical panel areas to assure that access to the panels is clear.

The Environmental Services Director or designee will audit weekly for 4 weeks, and monthly for 2 months to assure that electrical panel accesses are clear.


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