Pennsylvania Department of Health
VILLAGE AT PENN STATE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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VILLAGE AT PENN STATE, THE - 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 July 23, 2024, at The Village at Penn State, 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# 15550201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 23, 2024, it was determined that The Village at Penn State 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 building, with a partial basement, that 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: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of three floors.

Findings include:

1. Observation on July 23, 2024, at 9:40 a.m., revealed the basement-level, Supply Storage Room door was held open by unapproved means (gallon jug of cleaner).

Exit interview with the Facility Administrator at 11:00 a.m., on July 23, 2024, confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 08/26/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

K0321
1. The door to the basement level utility supply room was closed during the tour.
2. Signage was placed to not prop door open.
3. The environmental service director/ designee will educate housekeeping, laundry and maintenance staff that no supply room doors may be propped open.
4. The environmental service director/ designee will audit 2 random utility supply room doors to ensure proper closure weekly x 4 weeks and then monthly for 2 months. Audit results will be reported to the quality assurance and process improvement committee for further recommendation as needed.
5. Date of compliance August 26, 2024

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in one location, affecting one of three floors.

Findings include:

1. Observation on July 23, 2024, at 9:50 a.m., revealed the Dietary door exhibited a hole.

Exit interview with the Facility Administrator at 11:00 a.m., on July 23, 2024, confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 08/26/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

K0363
1. The kitchen door issue was identified prior to the survey and the part to repair the dietary door was on order.
2. The dietary door was repaired by an external vendor on July 25, 2024
3. Maintenance staff will complete inspection of facility corridor doors by the date of compliance. Corridor door inspection is on a preventative maintenance schedule.
4. The environmental service director/ designee will perform inspection of 2 random corridor doors monthly for 2 months. Audit results will be reported to the quality assurance and performance improvement committee for further recommendations as needed.
5. Date of compliance August 26, 2024

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 - Component: 01 - Tag: 0911

Based on documentation review and interview, it was determined the facility failed to maintain electrical systems, affecting two of three floors.

Findings include:

1. Observation on July 23, 2024, at 10:50 a.m., revealed the facility lacked annual receptacle testing data past April of calendar year 2023.

Exit interview with the Facility Administrator at 11:00 a.m., on July 23, 2024, confirmed the electrical systems deficiency.

Plan of Correction - To be completed: 08/26/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

K 0911
1. Receptacles in resident rooms are hospital grade. The facility follows guidance from NFPA 99, 2012 edition, chapter 6 section 3.3 which recommends testing to be conducted on initial installation, replacement or servicing of the device.
2. Standard outlets in resident rooms will be tested annually using approved testing device and method.
3. The environmental service director/ designee will review and revise if necessary, the policy and procedure titled "Receptacle Testing".
4. The environmental service director/ designee will audit 3 random standard resident room receptacles monthly for 2 months. Audit results will be reported to the quality assurance and performance improvement committee for further recommendation as needed.
5. Date of compliance August 26, 2024

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