Pennsylvania Department of Health
GREENERY CENTER FOR REHAB AND NURSING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GREENERY CENTER FOR REHAB AND NURSING - 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 20, 2024, at Greenery Center for Rehab and Nursing, 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# 135602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2024, it was determined that Greenery Center for Rehab and Nursing 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 non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors, affecting one of six smoke compartments.

Findings include:

1. Observation on May 20, 2024, at 10:36 a.m., revealed the self closing device was removed from the storage door in the west wing.

Interview with the Deputy Facility Administrator and Facility Maintenance Director on May 20, 2024, at 12:30 p.m., confirmed the above listed self-closing door deficiency.

Plan of Correction - To be completed: 05/31/2024

There has been a self closing device added to the west unit storage closet door.

An audit was completed on storage closest doors to ensure self closing device were present
The maintenance director or designee will educate staff on the importance of having a self closing device on the west unit storage closet door

The maintenance director/ designee will audit for self-closing devise on storage closest doors monthly X 2 to ensure that we are in compliance with Life Safety codes the results of the audit will be reported to the Quality assurance improvement committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of six smoke compartments.

Findings include:

1. Observation on May 20, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:20 a.m., there were multiple unsealed ceiling penetrations in the Respiratory Supply room;
b) 10:00 a.m., there were multiple unsealed ceiling penetrations in the Main Sprinkler room.

Interview with the Deputy Facility Administrator and Facility Maintenance Director on May 20, 2024, at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 05/31/2024

The facility has secured the ceiling penetrations that were observed in the Respiratory room and the Main Sprinkler room.

An audit was completed to observe for any additional ceiling penetrations by the maintenance director / designee
The maintenance Director / designee will add the respiratory room and Main Sprinkler room to the monthly checklist to observe for ceiling penetrations

The maintenance director will do an audit on ceiling penetrations in the respiratory room and main sprinkler room monthly X3. Results of the audit will be reported to the quality assurance improvement committee.

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