Nursing Investigation Results -

Pennsylvania Department of Health
KENDAL AT LONGWOOD
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
KENDAL AT LONGWOOD
Inspection Results For:

There are  40 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.
KENDAL AT LONGWOOD - 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 December 26, 2019, at Kendal at Longwood, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: WESTMORELAND - Component: 01 - Tag: 0000


Facility ID #110402
Component 01
Westmoreland Building

Based on a Medicare/Medicaid Recertification Survey completed on December 26, 2019, it was determined that Kendal at Longwood 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 frame 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: WESTMORELAND - 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, at three of seven common wall doors within the component.

Findings include:

1. Observation on December 26, 2019, between 11:50 AM and 12:05 PM, revealed common wall doors had gaps exceeding one eighth of an inch, at the following locations:

a. 11:50 AM, double corridor fire rated doors separating the Nursing Care from the Core Building, off the Main Lobby;
b. 12:00 PM, fire rated door separating the Nursing Care from the Core Building, at the Dish Room 212C, off the Main Lobby;
c. 12:00 PM, separating the Nursing Care from the Core Building, at the Dish Room 212C, off the Main Lobby;
d. 12:05 PM, separating the Nursing Care from the Core Building, at the Electrical Room 212B, off the Main Lobby.

Interview with the Plant Operations Manager on December 26, 2019, at 12:05 PM confirmed the common wall doors exceeded the allowed gap margins.






 Plan of Correction - To be completed: 02/24/2020

All four doors will be repaired to ensure that all gaps are less than one eighth inch by February 24, 2020. The Facilities Director will ensure that this work is completed.

In order to ensure that this deficiency does not reoccur, the 4-12 Night Watchman will monitor all rated and common wall doors in Westmorland (and between Westmorland and other areas) during his rounds, and take appropriate action and follow up if any are found to have gaps greater than 1/8 inch. He will document compliance daily for 30 days and then weekly for 2 months. After that time, documentation will be completed monthly for 9 months.

The Facilities Director will share the data collected with the Administrator and the compliance rate will be reported (monthly, for 12 months) to our Quality Assurance Performance Improvement Committee by the Administrator.

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: WESTMORELAND - Component: 01 - Tag: 0918

Based on observation and interview, the facility failed to provide an emergency stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observations on December 26, 2019, at 12:00 PM revealed the required remote manual stop station for the generator had not been installed. NFPA 110 - 3.5.5.6

Interview with the Plant Operations Manager on December 26, 2019, at 12:00 PM confirmed the switch had not been installed.


 Plan of Correction - To be completed: 02/24/2020

The remote stop for the generator will be installed in an appropriate and approved location by February 24, 2020.

The remote stop will be checked monthly by Maintenance (visual check) and will be tested for functionality semi-annually as a part of the generator's PM schedule. Any issues noted with these checks will be reported at QAPI by the Facilities Director.
Initial comments:Name: NEW ADDITION - Component: 04 - Tag: 0000


Facility ID #110402
Component 04
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on December 26, 2019, it was determined that Kendal at Longwood 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 (111), protected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: NEW ADDITION - Component: 04 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors of hazardous areas to positively latch, affecting one of two floors within the component.

Findings include:

1. Observation on December 26, 2019, at 12:15 PM revealed the double corridor door to Soiled Linen Room 4410 was not latching.

Interview with the Plant Operations Manager on December 26, 2019, at 12:15 PM confirmed the doors did not have positive latching.



 Plan of Correction - To be completed: 02/21/2020

The door will be repaired and fixed to ensure positive latching by February 21, 2020. The Facilities Director will ensure that this work is completed.

Nursing and Housekeeping staff will be educated about proper door closure and smoke barriers by the Administrator and the Housekeeping Supervisor. This education will be completed by 1/24/20.

In order to ensure that this deficiency does not reoccur, the 4-12 Night Watchman will monitor all corridor doors in Westmorland during his rounds, and take appropriate action and follow up if any are found to be latching improperly. He will document compliance daily for 30 days and then weekly for 2 months. After that time, documentation will be completed monthly for 9 months.

The Facilities Director will share the data collected with the Administrator and the compliance rate will be reported (monthly, for 12 months) to our Quality Assurance Performance Improvement Committee by the Administrator.


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: NEW ADDITION - Component: 04 - Tag: 0918
Based on observation and interview, the facility failed to provide an emergency stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observations on December 26, 2019, at 12:00 PM revealed the required remote manual stop station for the generator had not been installed. NFPA 110 - 3.5.5.6

Interview with the Plant Operations Manager on December 26, 2019, at 12:00 PM confirmed the switch had not been installed.


 Plan of Correction - To be completed: 02/24/2020

The remote stop for the generator will be installed in an appropriate and approved location by February 24, 2020.

The remote stop will be checked monthly by Maintenance (visual check) and will be tested for functionality semi-annually as a part of the generator's PM schedule. Any issues noted with these checks will be reported at QAPI by the Facilities Director.
Initial comments:Name: PT ADDITION - Component: 05 - Tag: 0000


Facility ID #110402
Component 05
PT Addition/Wellness Center

Based on a Medicare/Medicaid Recertification Survey completed on December 26, 2019, it was determined that Kendal at Longwood 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 three-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: PT ADDITION - Component: 05 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access to be readily accessible to a public way, on one of three floors within the component.

1. Observation on December 26, 2019, at 1:10 PM revealed both sets of Main Entrance/Exit sliding glass doors were equipped with a manually-operated hook locks. This lock would not allow the break-a-way door to operate properly, if activated.

Interview with the Plant Operations Manager on December 26, 2019, at 1:10 PM confirmed the Main Entrance exit doors could be blocked from opening in an emergency.



 Plan of Correction - To be completed: 02/24/2020

Plates will be installed over the latch opening of each door to make sure that they are not functional by February 24, 2020. The Facilities Director will ensure that this work is completed.

Visual checks of these plates will be made by the 4-12 watchman monthly and the Facilities Director will report any anomalies to the QAPI Committee on a quarterly basis.
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: PT ADDITION - Component: 05 - Tag: 0225

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

Findings include:

1. Observation on December 26, 2019, at 1:00 PM revealed the 1st floor stairtower door, from the 2nd floor Multi-purpose Room, had a gap greater than 1/8 inch.

Interview with the Director of Maintenance on December 26, 2019, at 1:00 PM confirmed the stairtower door exceeded the allowed gap margins.


 Plan of Correction - To be completed: 02/21/2020

The door will be repaired and fixed to ensure that all gaps are less than one eighth inch by February 21, 2020. The Facilities Director will ensure that these repairs occur.

In order to ensure that this deficiency does not reoccur, the 4-12 Night Watchman will monitor all corridor doors in Westmorland during his rounds, and take appropriate action and follow up if any are found to have gaps greater than 1/8 inch. He will document compliance daily for 30 days and then weekly for 2 months. After that time, documentation will be completed monthly for 9 months.

The Facilities Director will share the data collected with the Administrator and the compliance rate will be reported (monthly, for 12 months) to our Quality Assurance Performance Improvement Committee by the Administrator.


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: PT ADDITION - Component: 05 - Tag: 0918
Based on observation and interview, the facility failed to provide an emergency stop for the emergency generator, which supplies power to the entire component.

Findings include:

1. Observations on December 26, 2019, at 12:00 PM revealed the required remote manual stop station for the generator had not been installed. NFPA 110 - 3.5.5.6

Interview with the Plant Operations Manager on December 26, 2019, at 12:00 PM confirmed the switch had not been installed.


 Plan of Correction - To be completed: 02/24/2020

The remote stop for the generator will be installed in an appropriate and approved location by February 24, 2020.

The remote stop will be checked monthly by Maintenance (visual check) and will be tested for functionality semi-annually as a part of the generator's PM schedule. Any issues noted with these checks will be reported at QAPI by the Facilities Director.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port