Pennsylvania Department of Health
GROVE AT NEW CASTLE, 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 NEW CASTLE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Offsite Revisit to an Emergency Preparedness Survey completed on June 13, 2024, at The Grove at New Castle, 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 (SOUTH HALL BUILDING) - Component: 01 - Tag: 0000

Facility ID #100502
Component 01
Main Building

Based on an Offsite Revisit to a Medicare/Medicaid Recertification Survey completed on June 13, 2024, it was determined that The Grove at New Castle 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 V (000), unprotected, wood building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 (SOUTH HALL BUILDING) - Component: 01 - Tag: 0353

Based on document review and interview, the facility failed to maintain sprinkler system testing and maintenance requirements for two of two building components.

Findings include:

Document review on June 13, 2024, at 8:32 a.m., revealed the facility lacked documentation for a three-year, full flow trip test.

Interview with the administrator and maintenance director on June 13, 2024, at 8:32 a.m., confirmed the facility lacked documentation that the three-year, full flow trip test occurred within the last year.

*******************************************************************************
Based on document review and interview during an Offsite Revisit Survey conducted on August 9, 2024, at 10:00 a.m., the sprinkler system had additional deficiencies that include a DPV rebuild and leaking pipes. The facility was unable to provide documentation that the three-year, full-flow trip test occurred at the time of the Revisit Survey.
Interview with the maintenance supervisor on August 9, 2024, at 10:00 a.m., confirmed the deficiency listed above and has the repairs scheduled for August 15, 2024.

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

The three-year full flow trip test was not completed on time.

The three-year full flow trip test has was previously scheduled for completion on 7/2/2024. Contractor updated facility parts for repair would be available for a updated repair date of 8/15/2024 Paperwork will be provided to review.

The Maintenance Director will review scheduled tasks at the beginning of every month. All necessary inspections will be scheduled with the appropriate vendors.
Requests will be made to corporate for payments to vendors.
Results will be shared with the QAPI committee.

Initial comments:Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0000

Facility ID #100502
Component 02
West Wing

Based on an Offsite Revisit to a Medicare/Medicaid Recertification Survey completed on June 13, 2024, it was determined that The Grove at New Castle 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 II (222), fire resistive, wood building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0353

Based on document review and interview, the facility failed to maintain sprinkler system testing and maintenance requirements for two of two building components.

Findings include:

Document review on June 13, 2024, at 8:32 a.m., revealed the facility lacked documentation for a three-year, full flow trip test.

Interview with the administrator and maintenance director on June 13, 2024, at 8:32 a.m., confirmed the facility lacked documentation that the three-year, full flow trip test occurred within the last year.

*******************************************************************************
Based on document review and interview during an Offsite Revisit Survey conducted on August 9, 2024 at 10:00 a.m., the sprinkler system had additional deficiencies that include a DPV rebuild and leaking pipes. The facility was unable to provide documentation that the three-year, full-flow trip test occurred at the time of the Revisit Survey.
Interview with the maintenance supervisor on August 9, 2024, at 10:00 a.m., confirmed the deficiency and stated the repairs were scheduled for August 15, 2024.

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