Pennsylvania Department of Health
WOODHAVEN HEALTH & REHAB CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 37 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.


WOODHAVEN HEALTH & REHAB CENTER - 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 June 5, 2024, at Woodhaven Care Center, 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# 233102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 5, 2024, it was determined that Woodhaven Care Center 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 non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 three instances, affecting two of seven smoke compartments.

Findings include:

1. Observation on June 5, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:15 a.m., there were missing ceiling tiles outside the maintenance office on the first floor;
b) 9:30 a.m., storage was within 18 inches of the sprinkler head in the central supply room closet, on the first floor;
c) 9:50 a.m., there were multiple unsealed ceiling penetrations in the IT room, on the second floor.

Interview with the Facility Director of Nursing and Maintenance Director on June 5, 2024, at 11:00 a.m., confirmed the unsealed ceiling penetrations.

Plan of Correction - To be completed: 07/01/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Ceiling tiles outside the maintenance office on the first floor were replaced. The storage in the first floor supply room was reorganized so that everything was under 18 inches of the sprinkler head. Unsealed ceiling penetrations in the IT room.

Maintenance director audited all other rooms in the facility for any ceiling tiles needing replaced, unsealed ceiling penetrations, and anything within 18 inches of ceilings in storage and no other issues were identified.

To prevent this from happening again the NHA or designee will educate the maintenance director on the cited requirements for storage, ceiling tiles, and no ceiling penetrations.

To monitor and maintain on going compliance the maintenance director/designee will audit one unit of the facility weekly for 4 weeks and monthly for 2 months for the cited concerns.

Results will be taken to the QAPI for review and revision as needed.

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 01 - Component: 01 - Tag: 0363

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

Findings include:

1. Observation on June 5, 2024, at 9:25 a.m., revealed the door to room 218 on the second floor failed to latch when tested.

Interview with the Facility Director of Nursing and Maintenance Director on June 5, 2024, at 11:00 a.m., confirmed the corridor door deficiency.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting four of seven smoke compartments.

Findings include:

1. Observation on June 5, 2024, revealed the following smoke barrier door deficiencies:

a) 9:20 a.m., the smoke doors near the activities room, on the first floor, failed to latch when tested;
b) 9:55 a.m., the smoke doors near the nurse's station, on the second floor, failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on June 5, 2022, at 11:00 a.m., confirmed the smoke barrier door deficiencies.

Plan of Correction - To be completed: 07/01/2024

Maintenance director replaced the failing smoke door latches.

To prevent this from happening again the NHA or designee will educate the maintenance director on the cited requirements for smoke door latches.

To monitor and maintain on going compliance the maintenance director/designee will audit one unit of the facility for proper smoke door latches weekly for 4 weeks and monthly for 2 months.

Results will be taken to the QAPI for review and revision as needed.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform 2 of 12 required fire drills.

Findings include:

1. Review of documentation on June 5, 2024, at 8:30 a.m., revealed the facility lacked documentation for the first shift drill in the first quarter and the third shift drill for the second quarter.

Interview with the Facility Administrator and Maintenance Director on June 5, 2024, at 8:30 a.m., confirmed the facility lacked documentation for the drill between January and June in 2024.

Plan of Correction - To be completed: 07/01/2024

To prevent this from happening again the NHA or designee will educate the maintenance director on the cited requirements for fire drills on every shift every quarter.

To monitor and maintain on going compliance the maintenance director/designee will audit facility for fire drill compliance weekly for 4 weeks and monthly for 2 months.

Results will be taken to the QAPI for review and revision as needed.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

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.

Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0908

Based on document review and interview, it was determined the facility failed to maintain medical gas requirements in one instance, affecting the entire facility.

Findings include:

1. Review of Documentation on June 5, 2024, at 8:45 a.m., revealed the facility lacked documentation verifying that an annual medical gas system inspection was performed.

Interview with the Facility Administrator on June 5, 2024, at 8:45 a.m. confirmed the medical gas system inspection documentation was not available at the time of survey.

Plan of Correction - To be completed: 07/01/2024

Facility got medical gas system inspection scheduled to be completed at the earliest availability of the vendor.

To prevent this from happening again the NHA or designee will educate the maintenance director on the cited requirements for medical gas system annual inspections.

To monitor and maintain on going compliance the maintenance director/designee will audit facility for gas inspection compliance initially once completed and then annually thereafter.

Results will be taken to the QAPI for review and revision as needed.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on June 5, 2024, at 9:00 a.m., revealed the facility lacked documentation verifying that the following items were performed in the last 12 and 36 months:

a) 8:45 a.m., the triennial four-hour load test;
b) 9:00 a.m., the annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director, on June 5, 2024, at 9:00 a.m., confirmed the required annual and triennial generator testing documentation was not available at the time of the survey.

Plan of Correction - To be completed: 07/01/2024

Annual and triennial generator testing was completed by the maintenance director.

To prevent this from happening again the NHA or designee will educate the maintenance director on the cited requirements for generator testing.

To monitor and maintain on going compliance the maintenance director/designee will audit facility generator testing compliance weekly for 4 weeks and monthly for 2 months.

Results will be taken to the QAPI for review and revision as needed.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in two instances, affecting two of six smoke compartments.
Findings include:
1. Observation on June 5, 2024, at 9:50 a.m., revealed a coffee pot plugged into a surge protector in the admissions office, on the second floor.
Interview with the Facility Administrator and Maintenance Director on June 5, 2024, at 11:00 a.m., confirmed the misuse of electrical wiring.

Plan of Correction - To be completed: 07/01/2024

The coffee pot was unplugged from the surge protector.

To prevent this from happening again the NHA or designee will educate the maintenance director on the cited requirements for plugs in surge protectors.

To monitor and maintain on going compliance the maintenance director/designee will audit one unit of the facility for surge protector compliance weekly for 4 weeks and monthly for 2 months.

Results will be taken to the QAPI for review and revision as needed.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement