Nursing Investigation Results -

Pennsylvania Department of Health
INN AT FREEDOM VILLAGE, THE
Building Inspection Results

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INN AT FREEDOM VILLAGE, THE
Inspection Results For:

There are  36 surveys for this facility. Please select a date to view the survey results.

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INN AT FREEDOM VILLAGE, 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 5, 2020, at The Inn at Freedom Village, 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 #105502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 5, 2020, it was determined that The Inn at Freedom Village 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 two-story, Type II (222), fire resistive structure, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Installation: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.
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 document review and interview, it was determined the facility failed to address deficiencies listed on quarterly sprinkler inspection reports, affecting two of two floors within the component.

Findings include:

1. Review of documentation on February 5, 2020, between 8:00 AM and 10:30 AM revealed sprinkler inspection reports, dated June 17, 2019, and September 3, 2019, contained the following narrative, regarding the fire department connection (FDC): "This building has no FDC. It was probably assumed that the main building FDC on loading dock would supply this building but due to check valves in the pump room, that is not the case."
This building is required to have an FDC.

Interview with the Director of Maintenance on February 5, 2020, at 10:30 AM confirmed the sprinkler inspection report deficiencies.





 Plan of Correction - To be completed: 03/30/2020

The Facilities Director contacted Independence Fire and Sprinkler on 2/11/2020 to obtain quote to install FDC. Following installation, Facilities Director or designee to audit the functionality of the FDC quarterly times 12 months and afterwards as necessary. Facilities Director to monitor compliance through the Quality Assurance and Performance Improvement (QAPI) meeting quarterly times 12 months and afterwards as necessary.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain latching hardware of corridor doors, affecting one of two floors within the component.

Findings include:

1. Observation on February 5, 2020, at 12:05 PM revealed the door to the Closet, next to the Mechanical Room and Greenhouse, failed to positively latch within the door frame.

Interview with the Director of Maintenance on February 5, 2020, at 12:05 PM confirmed the door did not latch within the frame.




 Plan of Correction - To be completed: 03/30/2020

Facilities Director or Designee to contact Quality Doors to repair door. Facilities Director or designee to audit corridor doors monthly to assure functionality. Facilities Director or designee to monitor compliance at Quality Assurance and Performance Improvement (QAPI) meeting monthly times 6 months.
NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to provide documentation verifying staff had participated in a quarterly fire drill, affecting one of the previous twelve fire drill reports inspected for the component.

Findings include:

1. Review of documentation on February 5, 2020, between 8:00 AM and 10:30 AM revealed the facility did not provide documentation verifying 2nd shift staff members had participated in a fire drill, between February 21, 2019, and September 13, 2019.

Interview with the Director of Maintenance on February 5, 2020, at 10:30 AM confirmed the lack of documentation.




 Plan of Correction - To be completed: 03/30/2020

The Facilities Director to obtain a 12-month schedule from Life and Safety Solutions to ensure that all shifts receive a quarterly fire drill. Facilities Director or designee to audit the fire drill reports monthly times 6 months and afterwards as needed. Facilities Director or designee to monitor compliance at Quality Assurance and Performance Improvement (QAPI) meeting monthly times 6 months.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to provide a remote emergency shut off, for the generator, affecting two of two floors within the component.

Findings include:

1. Observation on February 5, 2020, at 1:46 PM revealed the generator lacked a remote manual stop station, outside of the Generator Room.

Interview with the Director of Maintenance on February 5, 2020, at 1:46 PM confirmed the lack of a manual emergency shut off, located outside of the Generator Room.




 Plan of Correction - To be completed: 03/30/2020

Facilities director to contact Power Plus to relocate remote manual stop station to outside of generator room. Facilities Director or designee to monitor functionality through quarterly auditing. Facilities Director or designee to monitor compliance at Quality Assurance and Performance Improvement (QAPI) meeting quarterly times 12 months.
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 segregate oxygen cylinders, full from empty, affecting one of two floors within the component.

Findings include:

1. Observation on February 5, 2020, at 11:31 AM revealed three oxygen cylinders considered empty, commingled within a majority of oxygen cylinders considered full, within the 2nd floor Oxygen Storage Room.

Interview with the Director of Maintenance on February 5, 2020, at 11:31 AM confirmed the cylinders were not separated, full from empty.






 Plan of Correction - To be completed: 03/30/2020

The facility immediately corrected the situation by separating the full and empty tanks in the Oxygen Storage Room. The Facilities Director or designee will in-service nursing staff regarding requirement to segregate empty cylinders from full cylinders. Facilities Director or designee to audit oxygen storage room weekly times 3 months to ensure that empty and full cylinders are segregated. Facilities Director or designee to monitor compliance at Quality Assurance and Performance Improvement Committee (QAPI) meeting monthly times 3 months and afterwards as necessary.
NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg: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 - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929

Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of two floors within the component.

Findings include:

1. Observation on February 5, 2020, at 11:30 AM revealed an unsecured oxygen cylinder, within the 2nd floor Oxygen Storage Room.

Interview with the Director of Maintenance on February 5, 2020, at 11:30 AM confirmed the cylinder was not secured.




 Plan of Correction - To be completed: 03/30/2020

The facility immediately secured the oxygen cylinder in the Oxygen Storage Room. The Facilities Director or designee will in-services nursing staff regarding requirement to secure portable oxygen cylinders. Facilities Director or designee to audit oxygen storage room weekly times 3 months to ensure compliance that portable oxygen cylinders are secured. Facilities Director or designee to monitor compliance at Quality Assurance and Performance Improvement Committee (QAPI) meeting monthly times 3 months and afterwards as necessary.



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