Pennsylvania Department of Health
AVALON SPRINGS PLACE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
AVALON SPRINGS PLACE
Inspection Results For:

There are  69 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.
AVALON SPRINGS PLACE - 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 27, 2023, at Avalon Springs Place, 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 - Component: 01 - Tag: 0000


Facility ID #132402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on December 27, 2023, it was determined that Avalon Springs Place was not in compliance with the requirements of the Life Safety Code for an existing healthcare 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 (000), unprotected, non-combustible building, with a ground floor, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 document review and interview, the facility failed to maintain regulations for one of one fire alarm system.

Document review on December 27, 2023, at 10:05 a.m., revealed the facility lacked documentation that the two-year sensitivity test had been completed at the time of the survey.

Interview with the maintenance technician and administrator on December 27, 2023, at 10:05 a.m., confirmed the sensitivity results were not available.










 Plan of Correction - To be completed: 02/15/2024

"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

- Fire alarm sensitivity is monitored daily by the built-in fire control monitoring system. Any needs are indicated on the systems information panel. Maintenance team monitors panel and addresses needs as indicated.

- Nursing Home Administrator will educate the Maintenance Director on the 2-year sensitivity testing requirement and ensure proper documentation proving testing was completed is maintained at the facility.

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 01 - Component: 01 - Tag: 0353

Based on observation, document review, and interview, the facility failed to maintain the fire sprinkler system for one of one system.

Findings include:

Document review on December 27, 2023, at 9:30 a.m., revealed no documentation available for the replacement and cailbration of fire sprinkler system gauges, per NFPA 25 requirements.

Interview with the maintenance technician and the administrator on December 27, 2023, at 9:30 a.m., confirmed the deficiency existed at the time of the survey.





 Plan of Correction - To be completed: 02/15/2024

-Fire sprinkler gauges calibrated or
replaced as listed below.

- Gage # 1 Main sprinkler inlet / replaced 2020 next scheduled replacement 2025

- Gage # 2 1st floor Sprinkler riser suppling 1st floor sprinkler system and ground floor system / Replaced 2020 / next scheduled replacement 2025

- Gage # 3 2nd floor riser suppling 2nd floor sprinkler system installed 2022 replacement 2027

-All gauges are inspected quarterly.

-Nursing home administrator will educate maintenance team on NFPA 25 requirements.

-Log will be maintained with Life Safety documentation.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation, review, and interview, the facility failed to meet smoke barrier construction requirments on one of three building levels.

Findings include:

Observation on December 27, 2023, at 11:11 a.m., revealed the basement decommissioned cooler room had a 12x12-inch hole in the ceiling as well as other smaller penetrations throughout the area, which would allow the passage of smoke.

Interview with the administrator and maintenance technician on December 27, 2023, at 11:11 a.m., confirmed the deficiency.





 Plan of Correction - To be completed: 02/15/2024

-Penetrations in the decommissioned basement cooler covered on 1/5/2024.

-Maintenance Director will educate the maintenance team on smoke barrier construction requirements.

-Monitoring for smoke barrier penetrations will be added to the facility's preventative maintenance schedule.

NFPA 101 STANDARD Electrical Systems - 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.
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 maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on one of four building levels.

Findings include:

Observation on December 27, 2023, between 10:55 a.m. and 10:59 a.m., revealed the following electrical system deficiencies:
A. (10:55 a.m.) Ground floor corridor, above ceiling tile, near door SD1-3, had a junction box with a cover missing;
B. (10:59 a.m.) Ground floor corridor, above ceiling tile, near door SD1-4, had uncapped/unprotected wires exposed.

Reference: NFPA 70-314.28 (C)

Interview with the maintenance worker and administrator on December 27, 2023, at 10:59 a.m., confirmed the electrical system deficiencies.





 Plan of Correction - To be completed: 02/15/2024

-Installed junction box cover above door SD1-3 on 12/27/2023.

-Traced wires verified no power to wires, pulled out all non-used wires above ceiling tile near door SD1-4 on 12/27/2023.

-Maintenance Director will educate team on electrical system requirements.

NFPA 101 STANDARD Electrical Systems - Receptacles: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 - 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 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles, per NFPA 70, in one of over twenty rooms.

Finding include:

Observation on December 27, 2023, at 11:10 a.m., revealed the laundry room clothes washers were plugged into outlets not protected by ground fault circuit interrupters (GFCI).

Interview with the maintenance technician and administrator on December 27, 2023, at 11:10 a.m., confirmed the receptacle deficiencies.







 Plan of Correction - To be completed: 02/15/2024

-Replaced the two standard receptacles in laundry room with GFCI receptacles on 1/5/2024.

-Maintenance director or designee will audit facility receptacles to ensure proper receptacles are used in all locations.

-Maintenance director will review NFPA 70 requirements with the maintenance team.


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