Pennsylvania Department of Health
GARDEN SPOT VILLAGE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDEN SPOT VILLAGE
Inspection Results For:

There are  41 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.
GARDEN SPOT 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 January 17, 2024, at Garden Spot 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 #14350200
Component 01
C Building

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that Garden Spot 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, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility lacked installed battery back-up emergency lighting at the emergency generator, affecting the entire component.

Findings include:

1. Observation on January 17, 2024, at 1:50 PM, revealed the Phase 2 Generator lacked an installed battery back-up emergency lighting.

Interview at the time of the exit conference with the Administrator, Director of Facilities Services and Facilities Services Supervisor on January 17, 2024, at 2:15 PM, confirmed the Phase 2 Generator lacked a installed battery back-up emergency lighting.



 Plan of Correction - To be completed: 02/29/2024

On 1/17/2024, it was observed that the facility lacked installed battery back-up emergency lighting at the emergency generator affecting Component 01.

Our facilities staff electricians reviewed the space on 1/18/2024, and (2) exterior battery back-up fixtures were sourced and ordered on 1/22/24. We anticipate the installation of both lights in the mechanical courtyard to take place no later than 2/29/24, per work order #173359.

They would be added to our work orders to test, which would ensure their operation and presence on a monthly basis.
NFPA 101 STANDARD Fire Drills: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.
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 conduct and perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on January 17, 2024, between 9:45 AM and 11:00 AM, revealed the facility did not perform fire drills every quarter, for the following shifts:

a. 2nd quarter 2023, 3rd shift;
b. 3rd quarter 2023, 3rd shift;
c. 4th quarter 2023, 3rd shift.

Interview at the time of the exit conference with the Administrator, Director of Facilities Services and Facilities Services Supervisor on January 17, 2024, at 2:15 PM, confirmed the fire drills were not performed.



 Plan of Correction - To be completed: 01/18/2024

On 1/17/24, it was determined that the facility failed to conduct and perform fire drills (one per shift, per quarter) affecting Component 01.

On 1/18/2024, the Facility Systems Specialist whom is responsible for Fire Drill implementation for the facility was made aware of the deficiency. A meeting took place between the Facility Systems Specialist, Facility Services Supervisor, and Director of Facility Services upon where the Facility Systems Specialist responsible for Fire Drills was re-educated on NFPA Standard 19.7.1.4 through 19.7.1.7, specifically the need for 3rd shift drills once per quarter.

On 1/18/2024, the Facility Services Specialist updated internal documentation to ensure that such drills would be accomplished, citing the need for one 3rd shift drill per quarter.

In addition, an annual Fire Drill work order (S.W.O. #5840) was created and assigned to Facility Systems Specialist, Facility Services Supervisor, and Director of Facility Services to solicit an annual plan and schedule of fire drill dates.
Initial comments:Name: NEW ADDITION - Component: 02 - Tag: 0000


Facility ID #14350200
Component 02
E Building

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that Garden Spot 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 (111), protected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: NEW ADDITION - Component: 02 - Tag: 0291

Based on observation and interview, it was determined the facility lacked installed battery back-up emergency lighting at the emergency generator, affecting the entire component.

Findings include:

1. Observation on January 17, 2024, at 1:50 PM, revealed the Phase 2 Generator lacked an installed battery back-up emergency lighting.

Interview at the time of the exit conference with the Administrator, Director of Facilities Services and Facilities Services Supervisor on January 17, 2024, at 2:15 PM, confirmed the Phase 2 Generator lacked a installed battery back-up emergency lighting.



 Plan of Correction - To be completed: 02/29/2024

Our facilities staff electricians reviewed the space on 1/18/2024, and (2) exterior battery back-up fixtures were sourced and ordered on 1/22/24.

We anticipate the installation of both lights in the mechanical courtyard to take place no later than 2/29/24, per work order #173359.

They would be added to our work orders to test, which would ensure their operation and presence on a monthly basis.
NFPA 101 STANDARD Elevators: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.
Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.)
19.5.3, 9.4.2, 9.4.3
Observations:
Name: NEW ADDITION - Component: 02 - Tag: 0531

Based on observation and interview, it was determined the facility failed to maintain elevator machine room door to be within allowed gap margins, affecting one of two smoke zones within the component.

Findings include:

1. Observation on January 17, 2024, at 12:50 PM revealed Elevator Machine Room door was greater than one eighth of an inch on the top and latch side.

Interview at the time of the exit conference with the Administrator, Director of Facilities Services and Facilities Services Supervisor on January 17, 2024, at 2:15 PM, confirmed the door exceeded the allowed gap margin.



 Plan of Correction - To be completed: 01/23/2024

On 1/18/2024, a door contractor was contacted and on that same day made a repair to the door.

On 1/18/2024, the door for E118 was added to our annual fire door inspection list per NFPA 80 which will ensure that this door is annually inspected.

On 1/23/24, the Facility Systems Specialist confirmed the repair to the E118 door met the NFPA standard of no gap greater than one eighth inch on the top and latch side.
NFPA 101 STANDARD Fire Drills: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.
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: NEW ADDITION - Component: 02 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct and perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on January 17, 2024, between 9:45 AM and 11:00 AM, revealed the facility did not perform fire drills every quarter, for the following shifts:

a. 2nd quarter 2023, 3rd shift;
b. 3rd quarter 2023, 3rd shift;
c. 4th quarter 2023, 3rd shift.

Interview at the time of the exit conference with the Administrator, Director of Facilities Services and Facilities Services Supervisor on January 17, 2024, at 2:15 PM, confirmed the fire drills were not performed.



 Plan of Correction - To be completed: 01/18/2024

On 1/18/2024, the Facility Systems Specialist whom is responsible for Fire Drill implementation for the facility was made aware of the deficiency.

A meeting took place between the Facility Systems Specialist, Facility Services Supervisor, and Director of Facility Services upon where the Facility Systems Specialist responsible for Fire Drills was re-educated on NFPA Standard 19.7.1.4 through 19.7.1.7, specifically the need for 3rd shift drills once per quarter.

On 1/18/2024, the Facility Services Specialist updated internal documentation to ensure that such drills would be accomplished, citing the need for one 3rd shift drill per quarter.

In addition, an annual Fire Drill work order (S.W.O. #5840) was created and assigned to Facility Systems Specialist, Facility Services Supervisor, and Director of Facility Services to solicit an annual plan and schedule of fire drill dates.

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