Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWS OF PRESBYTERIAN SENIORCARE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOWS OF PRESBYTERIAN SENIORCARE
Inspection Results For:

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WILLOWS OF PRESBYTERIAN SENIORCARE - 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 September 26, 2019, at Willows of Presbyterian Senior Care, 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# 161502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 26, 2019, it was determined that Willows of Presbyterian Seniorcare 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 four-story, Type II (222), fire resistive building, with a 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 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.
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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of 20 smoke compartments.

Findings include:

1. Observation on September 26, 2019, at 10:10 a.m., revealed the door to the dryer room on the ground floor failed to self-close and latch when tested.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed the door failed to latch on its own when released from the hold-open magnet.




 Plan of Correction - To be completed: 11/18/2019

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 are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. The corrective action put into place was:

The door to the dryer room on the ground floor was repaired. Door will now self-close and latch.

An inspection of Facility doors will occur to identify other doors that will not self-close and latch. Those found not to latch will be repaired so they latch when closed.

Audits will be conducted Quarterly of all facility doors to assure doors latch when closed. All those found not to be latching will be repaired. This audit will be taken to the QAPI committee for tracking and trending.

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 documentation review, observation and interview it was determined that the facility failed to maintain the automatic sprinkler and standpipe system in thirty-two instances, affecting the entire facility.

Findings include:

1. Documentation review on September 26, 2019, at 8:30 a.m., revealed the fire pump annual inspection report contained uncorrected deficiencies that could affect the performance and reliability of the fire pump and sprinkler system. The fire pump report from the three previous years shows the test header piping leaks excessive water onto the top of the fire pump controller during flow testing. It has been noted on the last three annual reports that this is a safety hazard and needs fixed.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 8:30 a.m., confirmed the fire pump deficiency.

2. Observation on September 26, 2019, revealed the following:

a) 9:40 a.m., there were items stored within eighteen inches of a sprinkler head deflector in the dietary office, inside of the basement dietary storage room;
b) 9:45 a.m., the protective cap was missing on the standpipe hose valve in the basement stairtower D;
c) 10:00 a.m., there was a physical therapy leg press machine stored up against a sprinkler head, obstructing the spray pattern, in the basement fan room (G503);
d) 10:05 a.m., the protective cap was missing on the standpipe hose valve in the kitchen by the freezers;
e) 10:07 a.m., there was a missing drop ceiling tile, behind the ceiling-mounted heater, in the basement kitchen receiving area;
f) 10:08 a.m., the protective cap was missing on the standpipe hose valve in the basement stairtower C;
g) 10:10 a.m., the protective cap was missing on the standpipe hose valve in the basement stairtower B;
h) 10:15 a.m., the protective cap was missing on the standpipe hose valve in the basement stairtower A;
i) 10:25 a.m., there was an unsealed pipe penetration, in the drop ceiling, in the first floor housekeeping closet (1602);
j) 10:28 a.m., the protective cap was missing on the standpipe hose valve in the first floor stairtower D;
k) 10:36 a.m., there was a missing drop ceiling tile in the first floor staff lounge;
l) 10:38 a.m., the protective cap was missing on the standpipe hose valve in the first floor stairtower C;
m) 10:40 a.m., the protective cap was missing on the standpipe hose valve in the first floor stairtower B;
n) 10:45 a.m., there were three loaded sprinkler heads in the first floor beauty salon (1607);
o) 10:47 a.m., the protective cap was missing on the standpipe hose valve in the first floor stairtower A;
p) 11:05 a.m., there was an unsealed pipe penetration, in the drop ceiling, in the fourth floor janitors closet (4417);
q) 11:08 a.m., the protective cap was missing on the standpipe hose valve in the fourth floor stairtower D;
r) 11:10 a.m., the protective cap was missing on the standpipe hose valve in the fourth floor stairtower C;
s) 11:12 a.m., the protective cap was missing on the standpipe hose valve in the fourth floor stairtower B;
t) 11:15 a.m., the protective cap was missing on the standpipe hose valve in the fourth floor stairtower A;
u) 11:18 a.m., there was a missing drop ceiling tile in the third floor janitor closet (3417);
v) 11:20 a.m., the protective cap was missing on the standpipe hose valve in the third floor stairtower D;
w) 11:22 a.m., the protective cap was missing on the standpipe hose valve in the third floor stairtower C;
x) 11:25 a.m., the protective cap was missing on the standpipe hose valve in the third floor stairtower B,
y) 11:28 a.m., the protective cap was missing on the standpipe hose valve in the third floor stairtower A;
z) 11:35 a.m., there was a missing drop ceiling tile in the second floor janitor closet (2417);
aa) 11:40 a.m., the protective cap was missing on the standpipe hose valve in the second floor stairtower D;
bb) 11:42 a.m., the protective cap was missing on the standpipe hose valve in the second floor floor stairtower C;
cc) 11:45 a.m., the protective cap was missing on the standpipe hose valve in the second floor stairtower B;
dd) 11:48 a.m., the protective cap was missing on the standpipe hose valve in the second floor stairtower A;
ee) 11:50 a.m., there was a damaged escutcheon, leaving an unsealed gap around the sprinkler head, in the corridor outside of the second floor room 2144.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed the sprinkler system deficiencies.











 Plan of Correction - To be completed: 11/18/2019

The Fire pump header pipe will be repaired.
Items within 18 inches of sprinkler head in the dietary office and the basement dietary storage room were moved.
Protective caps were placed on stand pipe hose valves located in the following Stair towers; Basement Stair Towers A, B, C and D. First floor Stair Towers A, B, C and D. Second floor Stair Towers A, B, C and D. Third floor Stair Towers A, B, C and D. Fourth floor Stair Towers A, B, C and D. Protective cap was placed on standpipe hose valve in the kitchen by freezer.
Item stored against the sprinkler head located in the basement fan room (G503) was moved.
Missing ceiling tile were replaced in the following areas; In the kitchen receiving area, in the first floor staff lounge, in the third floor janitor closet (3417) and in the second floor janitor closet (2417).
Unsealed Penetrations located in the first floor housekeeping closet (1602) and fourth floor janitor's closet (4417) were sealed.
Sprinkler heads located in the first floor beauty salon were cleaned to remove debris.
The damaged escutcheon around sprinkler head causing and unsealed gab near room 2144 was replaced.

Equipment inspection reports will be reviewed to assure all documented concerns have been addressed and repairs completed.
Maintenance staff will receive education by the Maintenance Director that Protective caps should be replaced on stand pipe hose valves if removed.
Facility staff will receive education conducted by the Maintenance Director or designee on the importance of not storing items against, and or within 18 inches of sprinkler heads.
An inspection of the building will occur to identify other unsealed penetrations. Any that are found will be sealed with fire rated stop {HILTI Putty Stick-CP 618}.
An inspection of the building will occur to identify other missing ceiling tile. Any that are found will be replaced.
An inspection of the building will occur to identify other sprinkler heads that may have debris or lint attached. Any that are found will be cleaned.
An inspection of the building will occur to identify other damaged escutcheons. Any that are found to be damaged will be replaced.

An inspection of the facility will occur monthly by the Maintenance Director or Designee to assure documented concerns on annual equipment inspection forms have been addressed, caps remain on stand pipe hose valves, sprinkler heads are free of debris, items are not stored against or within 18 inches of sprinkler heads and damaged escutcheon around sprinkler heads are replaced. All concerns will be taken to the QAPI committee for tracking and trending

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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of 20 smoke compartments.

Findings include:

1. Observation on September 26, 2019, at 10:38 a.m., revealed the smoke door to resident dining room 1108 on the first floor failed to self-close and latch when tested.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed the door failed to latch on its own when released from the hold-open magnet.



 Plan of Correction - To be completed: 11/18/2019

The smoke barrier door to resident dining on the first floor was repaired. Door will now self-close and latch.

An inspection of Facility doors will occur to identify other doors that will not self-close and latch. Those found not to latch will be repaired so they latch when closed.

Audits will be conducted Quarterly of all facility doors to assure doors latch when closed. All those found not to be latching will be repaired. This audit will be taken to the QAPI committee for tracking and trending.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based upon observation and interview, it was determined that the facility failed to maintain fire-rated door assemblies in one instance, affecting one out of over one-hundred doors inspected.

Findings include:

1. Observation on September 26, 2019, at 9:50 a.m., revealed there was no UL fire rated label on the fire door for the basement generator room (G508).

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed the fire door deficiency.





 Plan of Correction - To be completed: 11/18/2019

The fire door for the basement generator room (G508) will be inspected by an approved contractor and a UL fire rated label will be placed on the door. A written record of inspection will be maintained in the Maintenance Director's office.

An inspection of Facility doors will occur to identify other fire doors, to assure all have a UL fire rated label that is not only attached, but also legible. Those found not to be in compliance will have a new UL fire rated label attached.

Audits will be conducted Quarterly of all facility fire rated doors to assure UL fire rated label is still attached and legible. Fire doors found to be out of compliance will be inspected by an approved Contractor. These audits will be taken to the QAPI committee for tracking and trending.

NFPA 101 STANDARD Electrical Systems - Receptacles: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.
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, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one out of over two-hundred receptacles inspected.

Findings include:

1. Observation on September 26, 2019, at 10:50 a.m., revealed there was a wall-mounted power strip, within six feet of a sink, that was not GFCI protected.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed the electrical receptacle deficiency.




 Plan of Correction - To be completed: 11/18/2019

A GFCI receptacle was installed by the sink in the Dentist Clinic.

Receptacles located beside sinks were inspected to assure they were GFCI receptacles. Those found not to be approved GFCI receptacles were replaced

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for one of one emergency generators, affecting the entire facility.

Findings include:

1. Observation on September 26, 2019, at 9:50 a.m., revealed the facility lacked a remote manual stop station located outside of the generator enclosure.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed there was no remote manual stop station located outside of the generator enclosure





 Plan of Correction - To be completed: 11/18/2019

A remote manual emergency stop switch will be installed outside of the emergency generator enclosure.

The Maintenance Director or Designee will educate Maintenance staff on location and function of switch.
The manual emergency generator stop switch will be tested annually.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage requirements in one instance, affecting one of twenty smoke compartments.

Findings include:

1. Observation on September 26, 2019, at 10:12 a.m., revealed an oxygen storage area of greater than three-hundred cubic feet, in the basement loading dock area, did not have the required warning signage on the entrance door to the enclosure. Multiple oxygen cylinders were also found to be stored within five feet of combustibles.

Interview with the Facility Administrator and Maintenance Director on September 26, 2019, at 2:00 p.m., confirmed the oxygen cylinder storage deficiencies.





 Plan of Correction - To be completed: 11/18/2019

Oxygen cylinders were removed from the basement loading dock area.

The Director of Nursing or Designee educated Nursing and Central Supply staff that Oxygen cylinders are to be stored in the approved storage location on the dock.

Audits will be conducted by the Administrator or Designee daily for one week, then weekly for three weeks, then monthly. All Oxygen cylinders found not to be stored in the proper location will be moved and stored properly. Results will be reported at the quarterly QAPI meeting.


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