Nursing Investigation Results -

Pennsylvania Department of Health
NORMANDIE RIDGE
Building Inspection Results

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NORMANDIE RIDGE
Inspection Results For:

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NORMANDIE RIDGE - 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 12, 2019, at Normandie Ridge, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID# 250902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 12, 2019, it was determined that Normandie Ridge 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(111), protected wood frame structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to positively latch, and to be within the allowed gap margins, and the rating of the common walls, on two of three floors within the component.

Findings include:

1. Observation on September 12, 2019, between 12:00 PM and 12:30 PM, revealed common wall doors failed to positively latch, at the following locations:

a. 12:00 PM, Upper Level, separating Personal Care and Nursing Care, by the stairtower;
b. 12:30 PM, Lower Level, separating Personal Care and Nursing Care by the stairtower, at Rehab door.

Interview with the Director of Maintenance on September 12, 2019, at 12:30 PM confirmed the doors did not positively latch.


2. Observation on September 12, 2019, between 12:10 PM and 12:35 PM, revealed common wall doors had gaps exceeding one eighth of an inch, at the following locations:

a. 12:10 PM, Upper Level, separating Nursing Care from the Alcove Apartments;
b. 12:35 PM, Lower Level, separating Nursing Care from the Alcove Apartments.

Interview with the Director of Maintenance on September 12, 2019, at 12:35 PM confirmed the common wall doors exceeded the allowed gap margins.


3. Observation on September 12, 2019, at 12:30 PM revealed the common wall separating Personal Care and Nursing Care, by the stairtower at Rehab door, on the Lower Level, had 6-inch PVC pipes without fire collars, above the common wall doors.

Interview with the Director of Maintenance on September 12, 2019, at 12:30 PM confirmed the PVC pipes were not sealed with an approved system.




 Plan of Correction - To be completed: 11/04/2019

1. Upper and lower level doors separating personal and nursing care by the stair tower were adjusted to ensure positive latching. Upper and lower level doors between nursing care and the apartments will be adjusted, and hardware added as needed, to ensure gap does not exceed 1/8 inch. Fire collars will be installed on both sides of fire wall.
2. Environmental Services Director/designee will inspect fire doors quarterly, and with any type of adjustments to ensure facility maintains compliance with NPFA guidelines related to positive latching and gaps. Environmental Services Director/designee will audits fire collars annually to ensure secure installation. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.

NFPA 101 STANDARD Means of Egress - General: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.
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: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access corridors to be maintained clear and unobstructed, on one of three floors within the component.

1. Observation on September 12, 2019, between 1:09 PM and 1:50 PM revealed items were stored in the corridor, reducing the clear width to less than 60 inches, at the following locations:

a. 1:09 PM, Nurses' Med Cart, outside Resident Room 124;
b. 1:20 PM, Lift, outside Resident Room 117;
c. 1:50 PM, Nurses' Med Cart, outside Resident Room 101.

Interview with the Director of Maintenance on September 12, 2019, at 1:50 PM confirmed the corridor width was reduced to less than 60 inches.




 Plan of Correction - To be completed: 11/04/2019

1. Identified items were relocated to another area to ensure hallways were unobstructed. Facility will provide re-education to staff regarding regulatory requirements and appropriate storage of items to avoid obstruction of hallways in the event of an emergency.
2. Nursing Home Administrator/designee will complete audit of hallways 3 times/week x4 weeks, and then 10 monthly x2 months to ensure compliance. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on two of three floors within the component.

Findings include:

1. Observation on September 12, 2019, between 12:20 PM and 1:10 PM, revealed stairtower doors had gaps greater than one eighth of an inch, at the following locations:

a. 12:20 PM, upper level stairtower door;
b. 1:10 PM, center stairtower door, by Resident Room 124.

Interview with the Director of Maintenance on September 12, 2019, at 1:10 PM confirmed stairtower doors exceeded the allowed gap margins.




 Plan of Correction - To be completed: 11/04/2019

1. Upper level stair tower door and center stair tower door will be adjusted, and hardware added as needed to ensure gap does not exceed 1/8 inch.
2. Environmental Services Director/designee will inspect fire doors quarterly, and with any type of adjustments to ensure facility maintains compliance with NPFA guidelines related to gaps. Results of all audits will be reviewed at QAPI to ensure quality assurance and compliance


NFPA 101 STANDARD Horizontal Exits: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.
Horizontal Exits
Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4.
18.2.2.5, 19.2.2.5




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0226

Based on observation and interview, it was determined the facility failed to maintain rated doors to be within the allowed gap margins, on one of three floors within the component.

Findings include:

1. Observation on September 12, 2019, at 12:45 PM revealed the lower level double fire door, at the Northwest end of the building, had gaps, greater than 1/8 inch.

Interview with the Director of Maintenance on September 12, 2019, at 12:45 PM confirmed the rated door exceeded the allowed gap margins.



 Plan of Correction - To be completed: 11/04/2019

1. Northwest lower level double fire door will be adjusted, and hardware added as needed to ensure gap does not exceed 1/8 inch.
2. Environmental Services Director/designee will inspect fire doors quarterly, and with any type of adjustments to ensure facility maintains compliance with NPFA guidelines related to gaps. Results of all audits will be reviewed at QAPI to ensure quality assurance and compliance.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be wtihin the allowed gap margins, on one of three floors within the component.

Findings include:

1. Observation on September 12, 2019, at 1:15 PM revealed the door to the Lower Level Soiled Utility Room, by Resident Room 118, had gaps greater than 1/8 inch.

Interview with the Director of Maintenance on September 12, 2019, at 1:15 PM confirmed the hazardous area door exceeded the allowed gap margins.


 Plan of Correction - To be completed: 11/04/2019

1. Lower level soiled utility room door will be adjusted, and hardware added as needed to ensure gap does not exceed 1/8 inch.
2. Environmental Services Director/designee will inspect fire doors quarterly, and with any type of adjustments to ensure facility maintains compliance with NPFA guidelines related to gaps. Results of all audits will be reviewed at QAPI to ensure quality assurance and compliance.

NFPA 101 STANDARD Corridor - Doors: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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to be unobstructed, and to positively latch, in two of three smoke compartments within the component.

Findings include:

1. Observation on September 12, 2019, between 1:05 PM and 1:09 PM revealed the following corridor doors would not close and latch, due to the bathroom door being in the open position. When the bathroom door was opened, the corridor door would hit the bathroom door and prohibit it from closing:

a. 1:05 PM, Resident Room 129;
b. 1:07 PM, Resident Room 126;
c. 1:09 PM, Resident Room 124.

Interview with the Director of Maintenance on September 12, 2019, at 1:09 PM confirmed the corridor doors could not be closed due to obstruction from another door.


2. Observation on September 12, 2019, at 1:30 PM revealed the corridor door, to Resident Room 112, would not close and latch.

Interview with the Director of Maintenance on September 12, 2019, at 1:30 PM confirmed the corridor door did nto positively latch.



 Plan of Correction - To be completed: 11/04/2019

1. Mechanical closures will be added to bathroom doors to prohibit obstruction with corridor doors. Resident room 112 door was adjusted to positively latch.
2. Environmental Services Director/designee will audit bathroom doors bathroom doors quarterly to ensure there is no obstruction with the corridor doors. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.


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