Pennsylvania Department of Health
HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HEALTH CARE CENTER AT WHITE HORSE VILLAGE, 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 February 29, 2024, at The Health Care Center At White Horse Village, 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# 235902
Building 01
Health Care Center

Based on a Medicare/Medicaid Recertification Survey completed on February 29, 2024, it was determined that The Health Care Center At White Horse Village 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 two-story, Type II (111), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Installation:

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.

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system installation requirements, in one instance, affecting one of 14 smoke compartments.

Findings include:

Observation on February 29, 2024, at 12:35 p.m., revealed there were no sprinklers in the first floor kitchen walk-in cooler and freezer.

Interview with the Facility Administrator and Maintenance Director on February 29, 2024, at 2:00 p.m., confirmed the walk-in cooler and freezer did not have automatic sprinkler coverage.

Plan of Correction - To be completed: 04/29/2024

Automatic sprinkler system will be installed in the first-floor kitchen walk-in and freezer. System will be added to periodic preventive maintenance schedule for automatic sprinkler system. As part of this plan of correction, the applicable State authority will be contacted as requested to verify whether State approved drawing is required. If required, a time limited waiver will be requested. (Note: this revised POC is being submitted on 3/14/2024. Please clarify the telephone number to contact for plan review.)

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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, document review, and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.

Findings include:

Observation on February 29, 2024, at 10:45 a.m., revealed the gauges in both basement sprinkler riser rooms were dated 2018. The facility could not provide documentation that the gauges had been changed or recalibrated within the last five years.

Interview with the Facility Administrator and Maintenance Director on February 29, 2024, at 2:00 p.m., confirmed the facility lacked documentation, at the time of the survey, that the gauges have been changed or recalibrated within the last five years.

Plan of Correction - To be completed: 04/29/2024

Gauges part of the automatic sprinkler system in the basement riser rooms were changed on March 6, 2024. Gauges will be inspected, tested and maintained in accordance with applicable Standard.
Records of maintenance and inspection and testing will be maintained in the Facilities' Director office and will be readily available as necessary.
Records will document date gauges were checked, changed or recalibrated and who provided the service. Documentation will ensure and reflect that gauges will be changed or recalibrated ongoing within the required five-year period. Replacement gauges will be added to semi-annual inspections process and findings shared with Facilities Department leadership. In addition, Facilities staff will conduct and document a monthly visual inspection of all riser room sprinkler gauges. (Note: this POC was updated on 3/14/2024 and is being resubmitted for approval).

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 BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in two instances, affecting two of 14 smoke compartments.

Findings include:

Observation on February 29, 2024, revealed the following portable fire extinguishers would have to be recharged before use:

a) 12:47 p.m., the extinguisher near room 140 on the first floor;
b) 12:55 p.m., the extinguisher near room 149 on the first floor.

Interview with the Facility Administrator and Maintenance Director on February 29, 2024, at 2:00 p.m., confirmed the portable fire extinguisher pressure gauges indicated the extinguishers were undercharged.

Plan of Correction - To be completed: 04/29/2024

Fire extinguisher near room # 140 and fire extinguisher near room # 149 were replaced with fully charged extinguishers on 2/29/2024. These extinguishers will be included in the monthly inspection and annual service process. Compliance will be monitored by Security Services and Facilities leadership.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of a generator enclosure, for one of two emergency generators that provide emergency power to the healthcare facility. Installation shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 19.2.9, NFPA 101 (2012).

Findings include:

Observation on February 29, 2024, at 11:55 a.m., revealed the door to the main healthcare generator room, in the basement, failed to fully close and self-latch when tested.

Interview with the Facility Administrator and Maintenance Director on February 29, 2024, at 2:00 p.m., confirmed the door would not self-latch when tested.

Plan of Correction - To be completed: 04/29/2024

The door to the main healthcare generator room in the basement has been adjusted to fully close and self-latch on 2/29/2024. Audits and inspections of the performance of this door will be part of the preventive maintenance plan. Audit results will be received and reviewed by Facilities leadership.

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 one instance, affecting one of 14 smoke compartments.

Findings include:

Observation on February 29, 2024, at 12:57 p.m., revealed a microwave and refrigerator were plugged into a power strip in the IT office on the first floor.

Interview with the Facility Maintenance Director on February 29, 2024, at 12:57 p.m., confirmed the misuse of electrical wiring.

Plan of Correction - To be completed: 04/29/2024

The microwave and refrigerator in the IT office on the first floor were unplugged from a power strip in this space on 2/29/2024. Periodic audits and inspections of rooms will be conducted for proper maintenance of electrical wiring systems. Compliance reports will be received and reviewed by Facilities leadership.

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