Pennsylvania Department of Health
GARDENS AT WEST SHORE, THE
Building Inspection Results

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GARDENS AT WEST SHORE, THE
Inspection Results For:

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GARDENS AT WEST SHORE, 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 September 12, 2024, at the Gardens at West Shore, 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 #280202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 12, 2024, it was determined that the Gardens at West Shore 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 structure, with a partial basement, which 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: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access to be clear and unobstructed, in three of three smoke compartments within the component.

Findings include:

1. Observation on September 12, 2024, between 11:55 AM and 12:20 PM, revealed the corridor was obstructed from use, at the following locations:

a. 11:55 AM, 800 Wing Nurses' Station, outside the Med Cart Room, 3 med carts;
b. 12:20 PM, Resident Room 206, side chairs stored in the corridor.

Interview with the Director of Maintenance on September 12, 2024, at 12:20 PM, confirmed the corridor was obstructed from full use by storage.


2. Observation on September 12, 2024, between 11:50 am and 12:42 PM, revealed exit doors could not be opened without excessive force, at the following locations:

a. 11:50 AM, 800 Wing, double exit door;
b. 12:42 PM, 300 Wing, double exit door.

Interview with the Director of Maintenance on September 12, 2024, at 12:42 PM, confirmed the exit doors could not be opened without excessive force.


3. Observation on September 12, 2024, between 12:20 PM and 12:42 PM, revealed exit access was being used as a storage area, at the following locations:

b. 12:20 PM, exit vestibule the 200 Wing, combustible items;
c. 12:30 PM, Transport Room exit door, gurneys;
d. 12:32 PM, vestibule at the Transport Room exit, combustible items.

Interview with the Director of Maintenance on September 12, 2024, at 12:42 PM, confirmed exit access was not readily available.



 Plan of Correction - To be completed: 10/31/2024

1. All stated corridor and exit accesses were cleared of obstructions. Exit doors that could not be opened without excessive force will be adjusted to ensure compliance by Maintenance Director/Designee.

2. Maintenance Director/Designee will conduct an audit of corridor and exit accesses to ensure they are clear of obstructions daily until compliance is met and then weekly for 12 months. Maintenance Director/Designee will conduct an audit of exit doors to ensure they open without excessive daily until compliance is met and then weekly for 12 months. Results to QAPI.

3. Date of compliance 10/31/24

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide documentation of the sprinkler system inspections, affecting the entire component.

Findings include:

1. Review of documentation on September 12, 2024, between 8:50 AM and 10:40 AM, revealed the facility did not have documentation of the sprinkler system quarterly inspections performed, during the 4th quarter of 2023 and the 2nd quarter of 2024.

Interview with the Director of Maintenance on September 12, 2024, at 10:40 AM, confirmed the facility could not provide documented evidence of the quarterly inspections.



 Plan of Correction - To be completed: 10/31/2024

K0353

1. Documentation of 4th quarter 2023 and 2nd quarter 2024 sprinkler system inspections was located and placed in the Life Safety Binder.

2. Maintenance Director/designee will conduct an audit of the Life Safety book to confirm scheduling has happened and that reports have been received and filed appropriately 1x per month for 12 months. Results to QAPI.
NFPA 101 STANDARD Corridor - Doors: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.
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 were unobstructed from closing and could positively latch, in three of three smoke components within the component.

Findings include:

1. Observation on September 12, 2024, between 11:40 AM and 1:17 PM, revealed corridors doors were obstructed from closing, at the following locations:

a. 11:40 AM, Resident Room 803, obstructed by air mattress electrical cord;
b. 12:00 PM, 700 Wing Dining, dragging;
c. 12:40 PM, Resident Room 301, dragging;
d. 12:48 PM, Resident Room 507 was impeded by a waste basket;
e. 12:50 PM, Resident Room 509, hitting the frame;
f. 1:05 PM, Resident Room 911, dragging;
g. 1:17 PM, Resident Room 905, dragging.

Interview with the Director of Maintenance on September 12, 2024, at 1:17 PM, confirmed the corridor doors were obstructed from closing.


2. Observation on July 23, 2024, between 12:05 PM and 12:10 PM, revealed corridors doors failed to positively latch in the frame, at the following locations:

a. 12:05 PM, Resident Room 706;
b. 12:10 PM, Resident Room 607.

Interview with the Director of Maintenance on September 12, 2024, at 12:10 PM, confirmed the corridor doors failed to positively latch.




 Plan of Correction - To be completed: 10/31/2024

K0363

1. All stated obstructions blocking corridor doors were moved. Maintenance Director/Designee will adjust each stated corridor door that was dragging, hitting the frame, or not positively latching to ensure compliance.

2. Maintenance Director/Designee will conduct a facility audit of corridor doors to ensure they are not dragging, hitting the frame, or not positively latching. Any identified non-compliant doors will be adjusted and repaired.

3. Maintenance Director/Designee will conduct random audits monthly to ensure corridor doors close and positively latch properly for 12 months. Results to QAPI

3. Date of compliance 10/31/24

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide a path of travel, not greater than 200 feet to the smoke barrier doors, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on September 12, 2024, at 10:00 AM, revealed the 300-900 Wing smoke zone travel distance exceeded 200 feet from the furthest point in the zone to a door in the required smoke barrier wall, creating an extended smoke zone.

Interview with the Director of Maintenance on September 12, 2024, at 10:00 AM, confirmed travel distance to the smoke barrier exceeded 200 feet.



 Plan of Correction - To be completed: 10/31/2024

K0371

1. Facility requests DSI to conduct an FSES survey.

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0754

Based on interview and observations, it was determined the facility failed to limit trash and soiled linen to 32 gallons, in a 64-square foot area, outside of a protected hazardous area, in three of three smoke compartments within the component.

Findings include:

1. Observation on on September 12, 2024, between 11:58 AM and 1:00 PM, it was revealed that multiple areas had more than 32 gallons of trash and/or soiled linen, in a 64-square foot area, outside of a protected hazardous area, at the following locations:

a. 11:58 AM, 800 Wing Tub/Shower Room, 6 containers;
b. 12:07 PM, 400 Wing Tub/Shower Room, 6 containers;
c. 12:10 PM, 700 Wing Dining Room, 3 containers;
d. 12:25 PM, 200 Wing Shower Room, 6 containers;
e. 12:45 PM, 300 Wing Game Room, by Resident Room 307, 3 containers;
f. 1:00 PM, 700 Wing Tub/Shower Room, 3 containers.

Interview with the Director of Maintenance on September 12, 2024, at 1:00 PM, confirmed the trash and soiled linen exceeded 32 gallons were not stored in a protected hazardous area.



 Plan of Correction - To be completed: 10/31/2024

K0754

1. All stated areas having more than 32 gallons of trash and/or soiled linen, in a 64-square foot area were moved accordingly to establish compliance.

2. Maintenance Director/Designee will conduct an audit to ensure compliance with 32-gallon containers within 64 square foot areas daily during care hours until compliance is met then weekly for 12 months. Results to QAPI

3. Date of compliance 10/31/24

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Central Supply: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 and Vacuum Piped Systems - Central Supply System Operations
Adaptors or conversion fittings are prohibited. Cylinders are handled in accordance with 11.6.2. Only cylinders, reusable shipping containers, and their accessories are stored in rooms containing central supply systems or cylinders. No flammable materials are stored with cylinders. Cryogenic liquid storage units intended to supply the facility are not used to transfill. Cylinders are kept away from sources of heat. Valve protection caps are secured in place, if supplied, unless cylinder is in use. Cylinders are not stored in tightly closed spaces. Cylinders in use and storage are prevented from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon dioxide cylinders are prevented from reaching temperatures lower than manufacture recommendations or 20 degrees Fahrenheit. Full or empty cylinders, when not connected, are stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing motor-driven machinery, unless for instrument air reserve headers.
5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4, 5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0906

Based on observation and interview, it was determined the facility failed to secure oxygen cylinders, when in storage, in one of three smoke compartments within the component.
per NFPA 99 Edition 11.6.5.

Findings include:

1. Observation on September 12, 2024, at 12:30 PM, revealed an oxygen "E" cylinder was being stored, in the Transport Room vestibule, without being secured in a rack or chained.

Interview with the Administrator and the Director of Maintenance on September 12, 2024, at 12:30 PM, confirmed the cylinder was not secured.



 Plan of Correction - To be completed: 10/31/2024

K0906

1. Oxygen "E" cylinder stored in the transport room vestibule was promptly secured in a rack.

2. Maintenance Director/Designee will re-educate nursing staff on proper storage of oxygen "E" tanks.

2. Maintenance Director/Designee will conduct an audit to ensure oxygen "E" tanks are stored properly 3x per week for 4 weeks then monthly for 11 months. Results to QAPI.

3. Date of compliance 10/31/24

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain the electrical panels to be secured, in one of three smoke compartments within the component.

Findings include:

1. Observation on September 12, 2024, at 11:35 AM, revealed the Electrical Room and all the electrical panels in the 800 Wing were unlocked and accessible to any unauthorized persons.

Interview with the Director of Maintenance on September 12, 2024, at 11:35 AM, confirmed the room and panels were not secured against unauthorized access.



 Plan of Correction - To be completed: 10/31/2024

K0920

1. The electrical panels in the 800-wing electrical room were immediately locked.

2. Maintenance Director/Designee will conduct random audits monthly to ensure electrical panels are locked for 3 months. Results to QAPI

3. Date of compliance 10/31/24

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #280202
Component 02
Tower Building

Based on a Medicare/Medicaid Recertification Survey completed on September 12, 2024, it was determined that the Gardens at West Shore 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 three-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, on four of four floors within the component.

Findings include:

1. Observation on September 12, 2024, at 11:45 AM, revealed this building is a three-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered. This exceeds the maximum allowable story height for this type of construction.

Interview with the Director of Maintenance on September 12, 2024, at 11:45 AM, confirmed the facility exceeds the maximum allowable story height for this type of construction type.



 Plan of Correction - To be completed: 10/31/2024

K0161

1. Facility requests DSI to conduct an FSES survey. Facility has submitted the TLW with the plan of correction.

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: BUILDING 02 - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access, as unobstructed and available to full use in the event of an emergency, on one of three floors within the component.

Findings include:

1. Observation on September 12, 2024, at 11:35 AM, revealed the 1st floor exit door, to the outside by the Beauty Shop, could only be opened after several forceful tries and continued difficult to open after the initial opening.

Interview with the Director of Maintenance on September 12, 2024, at 11:35 AM, confirmed the exit access door required excessive force to open.



 Plan of Correction - To be completed: 10/31/2024

K0211

1. The stated exit door outside the beauty shop will be adjusted to ensure compliance.

2. Maintenance Director/Designee will conduct an audit of facility exit doors to ensure they open without difficulty. If any non-compliant doors are identified they will be adjusted or repaired to ensure compliance.

3. Maintenance Director/Designee will conduct an audit to ensure exit door compliance and exit door activation during monthly fire drills if exit door is in path of evacuation monthly for 12 months. Result to QAPI

3. Date of compliance 10/31/24

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: BUILDING 02 - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors, to positively latch, to be within the allowed gap margins and monitor the stairtowers for items stored, which don't serve the stairtower, on two of four floors within the component.

Findings include:

1. Observation on September 12, 2024, at 10:45 AM, revealed the 3rd floor stairtower double doors, by Rehab, failed to positively latch.

Interview with the director of Maintenance on September 12, 2024, at 10:45 AM, confirmed the stairtower doors failed to positively latch.


2. Observation on September 12, 2024, at 11:10 AM, revealed the 3rd floor West Stairtower door, by Resident Room 1344, had a gaps, greater than 3/16 inch.

Interview with the Director of Maintenance on September 12, 2024, at 11:10 AM, confirmed the door exceeded the allowed gap margins.


3. Observation on September 12, 2024, at 11:20 AM, revealed the stairtower on the 1st floor, behind the Kitchen, had a bike being stored under the landing.

Interview with the director of Maintenance on September 12, 2024, at 11:20 AM, confirmed the facility failed to keep items, which don't serve the stairtower, out of the stairtower.



 Plan of Correction - To be completed: 10/31/2024

K0225

1. The stated door gap and door latching issues will be adjusted to ensure compliance. The bike was removed from underneath the landing.

2. Maintenance Director/Designee will re-educate staff not storing items in stairtower corridors and promptly reporting door issues to the Maintenance Department when they are made aware.

2. Maintenance Director/Designee will conduct an audit to ensure door gap and positive latching compliance 3x per week for 4 weeks then monthly for 11 months. Results to QAPI

3. Date of compliance 10/31/24

NFPA 101 STANDARD Suite Separation, Hazardous Content, and Subd: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.
Suite Separation, Hazardous Content, and Subdivision
All suites are separated from the remainder of the building (including from other suites) by construction meeting the separation provisions for corridor construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved barriers shall be allowed to continue to be used provided they limit the transfer of smoke. Intervening rooms have no hazardous areas and hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of suites shall be by noncombustible or limited-combustible construction.
18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0255

Based on observation and interview, it was determined the facility failed to construct stairtowers, to be the minimum width and maintain the fire resistance of exit stairtower enclosures, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on September 12, 2024, at 12:01 PM, revealed the stair width, at the exterior discharge from the Laundry, was less than 44 inches.

Interview with the Director of Maintenance on September 12, 2024, at 12:01 PM, confirmed the width of the stairs was less than 44 inches.



 Plan of Correction - To be completed: 10/31/2024

K0255

1. The facility requests DSI to conduct an FSES survey.
NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0324

Based on document review and interview, it was determined the facility failed to inspect and clean cooking equipment, semi-annually, affecting the entire component.

Findings include:

1. Review of documentation on September 12, 2024, between 8:50 AM and 10:30 AM, revealed the facility could not provide documented evidence that the kitchen suppression system had been inspected, on a semi-annual basis. The only inspection for the suppression system was April 11, 2024.

Interview with the Director of Maintenance on September 12, 2024, at 10:30 AM confirmed the inspection was not done, semi-annually.


2. Review of documentation on September 12, 2024, between 8:50 AM and 10:30 AM, revealed Kitchen hood cleaning had not being cleaned, on a semi-annual basis. The only inspection for the hood cleaning was March 5, 2024.

Interview with the Director of Maintenance on September 12, 2024, at 10:30 AM, confirmed the hood cleaning was not done, semi-annually.



 Plan of Correction - To be completed: 10/31/2024

K0324

1. Documentation for the semi-annual kitchen suppression system was obtained and placed in the life safety binder.

2. Maintenance Director/designee will conduct an audit of the Life Safety book to confirm scheduling has happened and that reports have been received and filed appropriately 1x per month for 12 months. Results to QAPI.

3. Date of Compliance 10/31/2024.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 02 - Component: 02 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide documentation of the sprinkler system inspections, affecting the entire component.

Findings include:

1. Review of documentation on September 12, 2024, between 8:50 AM and 10:40 AM, revealed the facility did not have documentation of the sprinkler system quarterly inspections performed, during the 4th quarter of 2023 and the 2nd quarter of 2024.

Interview with the Director of Maintenance on September 12, 2024, at 10:40 AM, confirmed the facility could not provide documented evidence of the quarterly inspections.



 Plan of Correction - To be completed: 10/31/2024

K0353

1. Documentation of 4th quarter 2023 and 2nd quarter 2024 sprinkler system inspections was located and placed in the Life Safety Binder

2. Maintenance Director/designee will conduct an audit of the Life Safety book to confirm scheduling has happened and that reports have been received and filed appropriately 1x per month for 12 months. Results to QAPI.

3. Date of Compliance 10/31/2024

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0754

Based on observation and interview, it was determined the facility failed to maintain trash and soiled linen, exceeding 32 gallons, to be in a protected hazardous area, in one of three floors within the component.

Findings include:

1. Observation on September 12, 2024, at 11:00 AM, revealed 3 soiled-linen/trash containers were being stored in the Shower Room, by the Linen Chute Room, on the 3rd floor.

Interview with the Director of Maintenance on September 12, 2024, at 11:00 AM, confirmed the soiled-linen and trash was not stored in a protected hazardous area.


2. Observation on September 12, 2024, at 11:10 AM, revealed 3 soiled-linen/trash containers were being stored in the corridor, outside Resident Room 1335, on the 3rd floor.

Interview with the Director of Maintenance on September 12, 2024, at 11:10 AM, confirmed the soiled-linen and trash was not stored in a protected hazardous area.



 Plan of Correction - To be completed: 10/31/2024

K0754

1. All stated areas having more than 32 gallons of trash and/or soiled linen, in a 64-square foot area were moved accordingly to establish compliance.

2. Maintenance Director/Designee will re-educate facility staff that trash and soiled linen containers cannot exceed 32 gallons in any 64 square foot area.

3. Maintenance Director/Designee will conduct an audit to ensure compliance with 32-gallon containers within 64 square foot areas daily until compliance is met then weekly for 12 months. Results to QAPI

4. Date of compliance 10/31/24


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