Pennsylvania Department of Health
 WAVERLY HEIGHTS
Building Inspection Results

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WAVERLY HEIGHTS
Inspection Results For:

There are  42 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.
WAVERLY HEIGHTS - 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 May 6, 2024, at Waverly Heights, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BLDG (EAST,WEST,SOUTH, 2 NEW PATIENT ROOMS) - Component: 01 - Tag: 0000


Facility ID# 233402
Component 01
East, West, South Wings and Two New Patient Rooms

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2024, it was determined that Waverly Heights was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 III (211), protected ordinary building, with a lower level, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Initiation: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.
Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
Observations:
Name: MAIN BLDG (EAST,WEST,SOUTH, 2 NEW PATIENT ROOMS) - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain Fire alarm initiation devices, affecting one of two levels in the component.

Findings include:

Observation on May 6, 2024, at 10:49 a.m., revealed, in the lower level Pineapple Grill, the pull station was blocked by a food stand.

Exit interview with the VP of Building Services on May 6, 2024, at 11:00 a.m., confirmed the blocked pull station.



 Plan of Correction - To be completed: 05/15/2024

The food stand was moved away from the pull station.

Pull stations will be checked on daily rounds by building services staff to ensure that they are not obstructed.

Results of these audits will be reported at the quarterly QAPI meeting.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BLDG (EAST,WEST,SOUTH, 2 NEW PATIENT ROOMS) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of two levels in the component.

Findings include:

Observation on May 6, 2024, at 10:52 a.m., revealed, in the lower level Woodshop, the portable fire extinguisher was blocked by a workbench.

Exit interview with the VP of Building Services on May 6, 2024, at 11:00 a.m., confirmed the blocked pull station.



 Plan of Correction - To be completed: 05/17/2024

Work bench was moved away from the fire extinguisher.

Fire extinguishers will be checked on daily rounds by building services staff to ensure they are not obstructed.

Results of these audits will be reported at the quarterly QAPI meeting.
Initial comments:Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0000


Facility ID# 233402
Component 02
North Building

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2024, it was determined that Waverly Heights was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 (111), protected noncombustible building, with a lower level, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of three levels in the component.

Findings include:

Observation on May 6, 2024, at 10:07 a.m., revealed, in the upper level Linen Closet by resident room 250, the portable fire extinguisher needed to be mounted to the wall.

Exit interview with the VP of Building Services on May 6, 2024, at 11:00 a.m., confirmed the portable fire extinguisher needed to be mounted to the wall.



 Plan of Correction - To be completed: 05/15/2024

The portable fire extinguisher in the upper level Linen Closet by resident room 250 was mounted on the wall.

Portable fire extinguishers will be checked on daily rounds by building services staff to ensure they are properly mounted.

Results of these audits will be reported at the quarterly QAPI meeting.
NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire rating of trash chute, affecting one of three levels in the component.

Findings include:

Observation on May 6, 2024, at 10:11 a.m., revealed, in the upper level Trash Room near resident room 257, the trash chute door failed to latch.

Exit interview with the VP of Building Services on May 6, 2024, at 11:00 a.m., confirmed the door failed to latch.



 Plan of Correction - To be completed: 05/15/2024

The upper level trash room chute door near resident room 257 was repaired to latch properly.

Trash room chute doors will be checked by building services staff on a weekly basis for proper latching.

Results of these audits will be reported at the quarterly QAPI meeting.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain gas cylinder and container store rooms, affecting one of three levels in the component.

Findings include:

Observation on May 6, 2024, at 10:25 a.m., revealed, in the lower level Oxygen Storage Room, the room lack signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Exit interview with the VP of Building Services on May 6, 2024, at 11:00 a.m., confirmed the lack of signage.



 Plan of Correction - To be completed: 05/20/2024

A sign reading "CAUTION: OXIDIZING GASES STORED WITHIN NO SMOKING"
will be hung in the lower level Oxygen Storage Room.

Building services staff will check oxygen rooms on a weekly basis to ensure proper signage is in place.

Results of these audits will be reported at the quarterly QAPI meeting.
Initial comments:Name: EAST ADDITION - Component: 04 - Tag: 0000


Facility ID# 233402
Component 04
East Addition

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2024, at Waverly Heights, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing 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 lower level and partial basement, that is fully sprinklered.






 Plan of Correction:



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