Pennsylvania Department of Health
FAIRVIEW MANOR
Building Inspection Results

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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.


FAIRVIEW MANOR - 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 14, 2024, it was determined that Fairview Manor had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training 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.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to develop an emergency preparedness plan that included annual staff training for one of one plan.

Findings include:

Document review on May 14, 2024, at 11:50 a.m., revealed the facility lacked documentation that all staff members underwent annual emergency preparedness training within the previous twelve months.

Interview with the maintenance supervisor on May 14, 2024, at 11:50 a.m., confirmed the facility lacked this documentation.

Plan of Correction - To be completed: 06/07/2024

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Fairview Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Fairview Mano
r credible allegation of compliance.

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored

Education will be provided to staff on the emergency preparedness plan annually.

2) What quality assurance program will be put into place

Findings will be reviewed at the monthly QAPI meeting.

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

Facility ID #320802
Component 01
Main Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on May 14, 2024, it was determined that Fairview Manor 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 building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on observation and interview, the facility failed to maintain emergency lighting, in accordance with regulations, affecting one of two building levels.

Findings include:

Observation on May 14, 2024, at 10:55 a.m., revealed the basement transfer switch room's battery back-up emergency light did not illuminate when the test button was pressed.

Interview with the maintenance technician on May 14, 2024, at 10:55 a.m., confirmed the emergency light deficiency.

Plan of Correction - To be completed: 06/07/2024

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored

Battery in the basement transfer switch room has been changed and illuminates when the test button is pressed.

2) What quality assurance program will be put into place

Back up batteries for emergency lights will be kept in house

Findings will be reviewed at the monthly QAPI meeting.

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, the facility failed to maintain the sprinkler system on one of two building levels.

Findings include:

Observation on May 14, 2024, at 9:57 a.m., revealed the first floor laundry room had sprinkler heads covered in lint, potentially causing a delay in sprinkler activation.

Interview with the maintenance technician on May 14, 2024, at 9:57 a.m., confirmed the sprinkler heads were coated in lint.

Plan of Correction - To be completed: 06/07/2024

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored

The following sprinkler heads have been cleaned:
first floor laundry room sprinkler heads

2) What quality assurance program will be put into place

Sprinkler heads will be monitored a minimum of biweekly to ensure no dust or lint present.

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 document review and interview, the facility failed to maintain, conduct, and complete fire drills, in accordance with regulations, affecting the entire facility.

Findings include:

Document review on May 14, 2024, at 11:15 a.m., revealed the facility failed to provide fire drill documentation for the following shifts:
A.Second shift, second quarter;
B.First shift, third quarter;
C.Second shift, third quarter;
D.Third shift, third quarter.
Interview with the director of maintenance on May 14, 2024, at 11:15 a.m., confirmed the fire drill documentation was unavailable.

Plan of Correction - To be completed: 06/07/2024

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored

Fairview Manor will maintain, conduct, and complete fire drills, in accordance with regulations

2) What quality assurance program will be put into place

Environmental Services director or designee will ensure all fire drills are completed on each shift/ quarter as they are required.

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