Pennsylvania Department of Health
LOCUST GROVE RETIREMENT VILLAGE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 37 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.


LOCUST GROVE RETIREMENT VILLAGE - 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 May 15, 2024, it was determined that Locust Grove Retirement Village had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

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.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, it was determined the facility did not include a documented, facility-based and community-based risk assessment, which affects the entire component.

Findings include:

1. Review of documentation on May 15, 2024, between 9:30 AM and 11:30 AM, revealed the facility did not have an updated risk assessment included in the Emergency Preparedness Plan.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed the facility could not provide a risk assessment, at the time of the survey, required to be in place by November 15, 2017.

Plan of Correction - To be completed: 06/29/2024

1. The required annual review and update of the facility's Federal Emergency Preparedness Plan (Fed EPP) risk assessment will be properly documented.
2. There is only one required Fed EPP, therefore no additional reviews were needed.
3. The Executive Director educated the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73- Plan Based on All Hazards Risk Assessment specific to maintaining documentation of the required review and update of the facility's Federal Emergency Preparedness Plan (Fed EPP) risk assessment annually, this item will be added to the facility's TELS Preventative Maintenance (PM) Calendar, and will continue to be monitored in accordance with the standard.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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

Facility ID #123402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, it was determined that Locust Grove Retirement 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 one-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review, observation and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation, observation and interview on May 15, 2024, between 9:30 AM and 11:30 AM, revealed the facility lacked portable, accurate life safety drawings of the facility. Floor plans lacked resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and door swings.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed the lack of portable, accurate life safety drawings of the facility.

2. Review of documentation, observation and interview on May 15, 2024, between 9:30 AM and 11:30 AM, revealed the facility lacked documentation, verifying evacuation and alarm protocols, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed lack of documentation for evacuation and alarm protocols, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Plan of Correction - To be completed: 06/29/2024

1. The facility will provide Life Safety drawings and documentation verifying evacuation and alarm protocols.
2. There is only one requirement for providing Life Safety drawings and documentation verifying evacuation and alarm protocols, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 General requirements- Other specific to properly maintaining Life Safety drawings on-site, as well as documentation verifying evacuation and alarm protocols, and will continue to monitor in accordance with NFPA standards. An audit of the life safety book will be conducted at a minimum of annually prior to the opening of the survey window.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins, and obscured fire rating label, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on May 15, 2024, at 12:00 PM, revealed the Clean Linen door, in the Service Hall Main Laundry, had the fire rating label painted over and was obscured.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed the fire rated label was painted over.

2. Observation on May 15, 2024, at 12:03 PM, revealed the Clean Linen fire door, in the Service Hall Main Laundry, exceeded minimum gap 3/16, top.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed the doors exceeded allowed gap margins.

Plan of Correction - To be completed: 06/29/2024

The fire rating label noted to be obscured on the Clean Linen door in the Service Hall Main Laundry has been made legible, and the noted gap will be corrected with a fire door gap system
Additional hazardous area doors will be reviewed for proper labelling and excessive gaps. Other doors will be audited at a minimium of quarterrly.
The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Hazardous Areas- Enclosure specific to maintaining hazard room doors to proper function, and will continue to audit the doors monthly x 3 months.
Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to provide semi-annual hood cleanings of the fixed chemical fire suppression system, in one of two smoke compartments within the component.

Findings include:

1. Review of documentation on May 15, 2024, between 9:30 AM and 11:30 AM, revealed the facility could not provide documentation, verifying the Kitchen exhaust ductwork had been cleaned, on a semi-annual basis. Documentation, verified last cycle, was completed on June 28, 2023.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed the facility could not provide Kitchen ductwork had been cleaned, semi-annually.

Plan of Correction - To be completed: 06/29/2024

1. Documentation of the required semi-annual Kitchen hood vent cleaning was provided by a qualified vendor.
2. There is only one Kitchen hood vent, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Cooking Facilities specific to properly maintaining documentation of the required semi-annual hood vent cleaning / fire suppression system on a quarterly basis to ensure the latest report has been received and the next cleaning has been scheduled with the vendor. This item will be added to the facility's TELS Preventative Maintenance (PM) Calendar, and will continue to be monitored in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to perform quarterly inspections of the fire suppression water tank and failed to maintain the automatic sprinkler piping system, to be free of extraneous weight, affecting the entire component.

Findings include:

1. Review of documentation and interview, on May 15, 2024, between 9:30 AM and 11:30 AM, revealed the facility failed to perform quarterly exterior fire suppression tank inspections, as required.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed the facility failed to perform quarterly inspection of exterior suppression water tank.

2. Observation on May 15, 2024, at 1: 00 PM, revealed multiple wires wire tied to the sprinkler bracket and multiple wires across sprinkler pipes, in 400 Hall, above the ceiling, by the smoke doors.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed various items being supported by automatic sprinkler system.

Plan of Correction - To be completed: 06/29/2024

1. The required quarterly exterior fire suppression tank inspections will be properly documented, and the wires noted across the brackets and sprinkler pipes in 400 Hall above the ceiling by the smoke doors will be removed.
2. There is only one required quarterly exterior fire suppression tank inspection, therefore no additional reviews were needed. Additional sprinkler piping above the ceiling will be reviewed for improperly attached wiring.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Sprinkler System- Maintenance and Testing specific to properly maintaining the fire sprinkler system. The quarterly exterior fire suppression tank inspections will be added to the facility's TELS PM Calendar, and will continue to be monitored in accordance with NFPA standards. Audits will be performed on a quarterly basis and prn with any work order for above the cieling repairs.
4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles, to be Ground Fault Interruption (GFI) protected, within six feet of a water source, in two of two smoke compartments within the component.

Findings include:

1. Observation on May 15, 2024, between 11:35 AM and 1:05 PM, revealed outlets were not GFI protected and within six feet of a water source, at the following locations:

a. 11:35 AM, Laundry Washroom, beside the sink;
b. 12:15 PM, Kitchen, produce wash sink, 2 outlets;
b. 1:05 PM, Soiled Utility Room, right wall of sink.

Interview at the time of the exit conference with the Administrator and Director of Maintenance on May 15, 2024, at 1:30 PM, confirmed outlets were not GFI protected.

Plan of Correction - To be completed: 06/29/2024

1. Outlets within 6 ft. of a water supply, noted in the Laundry Washroom beside the sink, in the Kitchen near the produce wash sink, and in the Soiled Utility Room on the right wall of sink will be replaced with GFCI receptacles.
2. Additional outlets located within 6 ft. of a water supply will be reviewed for being GFCI receptacles.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Systems- Receptacles specific to installing GFCI receptacles with 6 ft. of a water supply, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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