Pennsylvania Department of Health
WINDY HILL VILLAGE OF THE PRESBYTERIAN HOMES
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 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.


WINDY HILL VILLAGE OF THE PRESBYTERIAN HOMES - 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 August 14, 2024, at Windy Hill Village of the Presbyterian, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID# 164302
Component 03
Building 03

Based on a Medicare/Medicaid Recertification Survey completed on August 14, 2024, it was determined that Windy Hill Village of the Presbyterian 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 V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of one floor.

Findings include:

1. Observation on August 14, 2024, at 11:03 a.m., revealed the common wall door with the 04 Component required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, at 12:30 p.m.,confirmed the common wall deficiency.

Plan of Correction - To be completed: 09/17/2024

Identified issue of misaligned door, which was adjusted to ensure the latch worked properly Applied lubricant to the latch mechanism and hinges to ensure smooth operation. Door now functioning properly.

Additional doors identified throughout this survey process were inspected to ensure the latches worked properly. Details in the corrective action plans indicated with the appropriate K Tags following in this document.

Provided training to maintenance staff on proper door adjustment repair and inspection techniques to ensure effective resolution of similar issues.

Implemented an inspection program for all doors to prevent recurrences of similar issues. A fire door inspection checklist will be utilized, with inspections scheduled monthly to ensure ongoing compliance and functionality. Findings from inspections conducted will be presented to the Quality Assurance Performance Improvement (QAPI) committee for any recommendations or further discussions.

NFPA 101 STANDARD Emergency Lighting:

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.

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: BUILDING 03 - Component: 03 - Tag: 0291

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting in multiple locations, affecting two of two floors, within two of three components.

Findings include:

1. Observation on August 14, 2024, at 11:15 a.m., revealed the facility lacked comprehensive, emergency lighting testing data, with respect to both thirty-second, monthly testing, as well as annual ninety-minute, bleed, or "drain" testing.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m.,confirmed the emergency lighting deficiency.

Plan of Correction - To be completed: 09/17/2024

Performed the required 30-second monthly test and 90-minute battery drain test for all emergency lighting to establish current operational status. Evaluated the current procedures for emergency lighting testing to ensure they meet regulatory requirements. Established a standardized procedure for performing the 30-second monthly tests and 90-minute annual tests to include documentation for each test, including the date, time, and results.

Provided training to staff on the importance of emergency lighting testing, proper procedures, and accurate documentation.

Developed a comprehensive log to record all emergency lighting tests. Included fields for the date, time, duration, results, and any corrective actions taken. Findings from inspections conducted will be presented to the Quality Assurance Performance Improvement (QAPI) committee for any recommendations or further discussions.

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: BUILDING 03 - Component: 03 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of one floor.

Findings include:

1. Observation on August 14, 2024, at 10:50 a.m., revealed biohazard storage items blocked access to the sprinkler system, located within the sprinkler room.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m.,confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 09/17/2024

Removed all biohazard storage items blocking access to the sprinkler system. Ensured a clear path is established for easy access to all components of the sprinkler system. Relocated biohazard storage items to an appropriate and designated area that does not interfere with access to safety equipment.

Educated staff on the importance of maintaining a clear path to the sprinkler system.

Implemented regular monthly inspections to ensure compliance with safety and accessibility standards.

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: BUILDING 03 - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of one floor.

Findings include:

1. Observation on August 14, 2024, at 10:48 a.m., revealed the building services corridor door required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 09/17/2024

Inspection indicated misalignment which was adjusted to ensure the latch worked properly. Applied lubricant to the latch mechanism and hinges to ensure smooth operation. Door now functioning properly.

Provided training to maintenance staff on proper door adjustment repair and inspection techniques to ensure effective resolution of similar issues.

Implemented an inspection program for all doors to prevent recurrences of similar issues. A door inspection checklist will be utilized, with inspections scheduled monthly to ensure ongoing compliance and functionality. Findings from inspections conducted will be presented to the Quality Assurance Performance Improvement (QAPI) committee for any recommendations or further discussions.

NFPA 101 STANDARD Operating Features - Other:

Operating Features - Other
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features 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 in Form CMS-2567.

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0700

Based on documentation review and interview, it was determined the facility failed to maintain fire doors in multiple instances, affecting two of two floors, within three of three components.

Findings include:

1. Observation on August 14, 2024, at 11:05 a.m., revealed the facility lacked comprehensive fire door, annual inspection data for the preceding twelve month period.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the fire door deficiency.

Plan of Correction - To be completed: 09/17/2024

A thorough, facility-wide inspection of all fire doors has been conducted, and the findings are documented in an audit report identifying doors are in compliance with the 12-point Activity checklist.

Provided training to maintenance staff on proper fire door inspection techniques.

Implemented an inspection program for all fire doors. A fire door inspection checklist in accordance to the 12-point will be utilized, with inspections scheduled monthly to ensure ongoing compliance and functionality. Findings from inspections conducted will be presented to the Quality Assurance Performance Improvement (QAPI) committee for any recommendations or further discussions

NFPA 101 STANDARD Fire Drills:

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: BUILDING 03 - Component: 03 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to maintain fire drills in four instances, affecting two of two floors, within three components.

Findings include:

1. Observation on August 14, 2024, at 11:00 a.m., revealed the facility lacked four of twelve required fire drills, for the preceding twelve month period (second and third shift, third quarter of 2023, and second and third shift, fourth quarter of 2023).

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 09/17/2024

The facility was unable to produce four of the twelve required fire drill documents for the second and third shifts in the third quarter, as well as the second and third shifts in the fourth quarter of 2024. Consequently, the facility is currently unable to reconstruct or conduct these past fire drills.

The maintenance department has been trained on the proper requirements and procedures for conducting monthly fire drills.

A tracking log has been established to monitor compliance with the scheduled shift times and fire drill requirements to be monitored by the Executive Director and/or designee.

The results from the tracking tool will be reviewed by the facility's Quality Assurance and Performance Improvement (QAPI) committee for further analysis and recommendations, if necessary.

NFPA 101 STANDARD Electrical Systems - Other:

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: BUILDING 03 - Component: 03 - Tag: 0911

Based on documentation review and interview, it was determined the facility failed to maintain electrical systems in multiple locations, affecting two of two floor, within three of three components.

Findings include:

1. Observation on August 14, 2024, at 11:18 a.m., revealed the facility lacked receptacle testing data for patient care areas, for the preceding twelve month period.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the receptacle testing data.

Plan of Correction - To be completed: 09/17/2024

The facility was unable to provide receptacle testing data for the past twelve months.

A receptacle testing inspection has been conducted, with another scheduled for six months. Findings of the inspection showed 100% of receptacles met the testing requirement. An inspection log will be used for this purpose, which includes fields for room/area, number of outlets, physical integrity (pass/fail), polarity (pass/fail), retention (pass/fail), and any additional comments.

The maintenance staff have been trained on the correct procedures and policy guidelines for conducting receptacle testing inspections to ensure consistency and compliance.

The results from the receptacle testing will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee for further discussion and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain two generator sets, affecting two floor, within three of three components.

Findings include:

1. Observation on August 14, 2024, at 11:10 a.m., revealed the facility lacked required three year, four hour, load testing data for the preceding thirty-six month period. the facility also lacked a natural gas reliability letter.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the generator set deficiencies.

Plan of Correction - To be completed: 09/17/2024

The facility could not present the required three-year, four-hour load testing data for the preceding thirty-six-month period as well as the natural gas reliability letter from the gas supplier.

The facility has scheduled with Breon's Inc. and completed the required 3-year 4 hour load testing required on 8/28/2024.

The facility has contacted the gas supplier and requested the reliability letter as outlined in the regulatory guidelines. A reliability letter was received from the natural gas supplier on 8/28/2024 and filed in the appropriate binder.

Any findings regarding required testing will be presented to the Quality Assurance Performance Improvement committee for discussions and recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of one floor.

Findings include:

1. Observation on August 14, 2024, at 10:44 a.m., revealed a surge protector was in use within the D.O.N. Office (small coffee maker and small, personal-style refrigerator).

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 09/17/2024

The maintenance of electrical equipment, specifically power cords and extensions cords was not maintained in one location and was corrected by removal of this identified surge protector from the DON office.

A facility-wide inspection is being conducted and any unnecessary surge protectors will be removed and replaced with approved units as necessary. Ongoing inspections will continue to ensure we are adhering to the guidelines.

Management staff was educated on this infraction and the necessity to ensure all locations are following these guidelines and regulatory requirements.

An audit of areas throughout the facility will be conducted weekly for 4 (four) weeks, monthly for 2 months. The findings will be presented to the Quality Assurance Performance Improvement committee for recommendations and further discussions.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000

Facility ID# 164302
Component 04
Building 04

Based on a Medicare/Medicaid Recertification Survey completed on August 14, 2024, it was determined that Windy Hill Village of the Presbyterian 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, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access in one location, affecting one of two floors.

Findings include:

1. Observation on August 14, 2024, at 11:31 a.m., revealed multiple storage items were located within the second floor, 400 Wing, exit access corridor system.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the means of egress deficiency.

Plan of Correction - To be completed: 09/17/2024

The means of egress for hallway 400 was not maintained to continuously allow for easy exit. Although this hallway is decertified it still must be maintained in accordance with Chapter 7 of the NFPA 101 "Means of Egress".

To fulfill regulatory requirements, the facility has conducted a comprehensive inventory and review of all equipment, furniture, and other items on the unit. Items deemed irreparable or unsuitable for use have been removed and properly disposed of. Additionally, all hallways have been cleared, and rooms have been arranged to ensure they are ready for use with no storage present.

Due to the unit being empty and not routinely being utilized, the maintenance department staff will routinely complete a walk-thru of the unit to ensure no items are being stored inappropriately.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: BUILDING 04 - Component: 04 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in multiple locations, affecting two of two floors.

Findings include:

1. Observation on August 14, 2024, between 11:14 a.m., and 11:33 a.m., revealed the following deficiencies:

a. 11:14 a.m., the first floor, Soiled Workroom door required adjustment to fully latch.
b. 11:33 a.m., many of the second floor, 400 Wing, former resident rooms were being used as storage occupancies, and doors lacked self-closing devices.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m.,confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 09/17/2024

A. The common wall door on the
first-floor soiled workroom.

Inspected the door to diagnose why it failed to fully latch. Checked for misalignment between the door and the door frame. Examined the latch, hinges, and other related hardware for wear, damage, or misalignment. Adjusted the latch mechanism to ensure the latch worked properly. Applied lubricant to the latch mechanism and hinges to ensure smooth operation. After making the necessary adjustments, tested the door to ensure it latches securely and functions properly from both sides. Fully latching after several closings.

Training was presented to the maintenance staff on proper door adjustment repair and inspection techniques to ensure effective resolution of similar issues.

Implemented an inspection program for all doors to prevent recurrences of similar issues. A fire door inspection checklist will be utilized, with inspections scheduled monthly to ensure ongoing compliance and functionality. Findings from inspections conducted will be presented to the Quality Assurance Performance Improvement (QAPI) committee for any recommendations or further discussions.

B. 400 wing rooms used for storage and
lacked self-closing devices.

The facility has conducted a comprehensive inventory and review of all equipment, furniture, and other items on the unit. Items deemed irreparable or unsuitable for use are being removed and properly disposed of between to timeframe of 9/4/2024 � 9//10/2024.

Upon removal of items from the unit, rooms are being arranged to ensure they are ready for use with no storage present.

Due to the unit being empty and not routinely being utilized, the maintenance department staff will routinely complete a walk-thru of the unit to ensure no items are being stored inappropriately.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: BUILDING 04 - Component: 04 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting one of two floors.

Findings include:

1. Observation on August 14, 2024, at 11:22 a.m., revealed non-rated foam insulating materials sealed two penetrations of the portion of the smoke barrier separation wall, located closest to Resident Room 202 (above the doors).

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the smoke barrier separation wall deficiency.

Plan of Correction - To be completed: 09/17/2024

The facility did not maintain one smoke barrier separation due to the use of non-rated foam insulating materials that were used to seal two penetrations of the portion of the smoke barrier separation wall.

Removed non-rated insulating foam and sealed around the two penetrations above the smoke barrier wall entering the 200 wing with 3M Fire Barrier Sealant (CP25WB+). Additionally, maintenance inspected all smoke barrier walls for any inappropriate sealing materials.

Maintenance was educated on this infraction an all understood the necessity to use the appropriate material.

Initial comments:Name: BUILDING 05 - Component: 05 - Tag: 0000

Facility ID# 164302
Component 05
Building 05

Based on a Medicare/Medicaid Recertification Survey completed on August 14, 2024, it was determined that Windy Hill Village of the Presbyterian 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 V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 05 - Component: 05 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting one of two floors.

Findings include:

1. Observation on August 14, 2024, between 11:40 a.m., and 11:44 a.m., revealed escutcheon plates were lacking in the following locations:

a. 11:40 a.m., within the Multipurpose Room.
b. 11:44 a.m., at the vending machine location.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 09/17/2024

In two locations the facility was missing escutcheon plates on sprinkler heads. One plate was found within the facility and placed on the sprinkler head. Another plate was ordered and will be placed upon receipt.

Liberty Fie Solutions along with maintenance will conduct a visual inspection of all sprinkler heads to ensure compliance on 9/9/2024 during the routine quarterly and semiannual fire system inspections.

An inspection of all sprinkler heads will be added to the monthly fire extinguisher inspections and the findings will be logged into the Fire Extinguisher Inspection form.

Maintenance was educated on the proper inspection techniques while conducting monthly fire extinguisher inspections.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: BUILDING 05 - Component: 05 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of two floors.

Findings include:

1. Observation on August 14, 2024, at 11:47 a.m., revealed the first floor, smoke barrier separation door, located closest to the Family Room, required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on August 14, 2024, between 12:20 p.m., and 12:30 p.m., confirmed the smoke barrier separation door deficiency.

Plan of Correction - To be completed: 09/17/2024

Inspected the common wall door to diagnose why it failed to fully latch. Checked for misalignment between the door and the door frame. Examined the latch, hinges, and other related hardware for wear, damage, or misalignment. Adjusted the latch mechanism to ensure the latch worked properly Applied lubricant to the latch mechanism and hinges to ensure smooth operation. After making the necessary adjustments, the doors were tested to ensure it latches securely and functions properly from both sides. Fully latching after several closings.

Provided training to maintenance staff on proper door adjustment repair and inspection techniques to ensure effective resolution of similar issues.

Implemented an inspection program for all doors to prevent recurrences of similar issues. A fire door inspection checklist will be utilized, with inspections scheduled monthly to ensure ongoing compliance and functionality. Findings from inspections conducted will be presented to the Quality Assurance Performance Improvement (QAPI) committee for any recommendations or further discussions.

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