Nursing Investigation Results -

Pennsylvania Department of Health
GREEN RIDGE CARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREEN RIDGE CARE CENTER
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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GREEN RIDGE CARE CENTER - 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 April 4, 2022, at Green Ridge Care Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: NEW BUILDING - Component: 03 - Tag: 0000


Facility ID# 332302
Component 03
Main Building

Based on a Medicare/Medicaid recertification survey completed on April 4, 2022, it was determined that Green Ridge Care Center 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 483.70(a)

This is a one story, Type V (111), protected, wood-frame structure which is fully-sprinklered.



 Plan of Correction:


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: NEW BUILDING - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of one floor.

Findings include:

1. Observation on April 4, 2022, at 12:16 p.m., revealed the 100 hallway soiled utility room door was not smoke-tight.

Exit interview with the Facility Administrator and the Facilities Manager on April 4, 2022, between 12:30 p.m. and 12:40 p.m., confirmed the hazardous area enclosure deficiency.



 Plan of Correction - To be completed: 04/26/2022

Preparation and/or execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. The Plan of Correction represents the facility's credible allegation of compliance.


The soiled utility doors located on the 100 hall has been adjusted to be smoke tight.

All doors were checked for gaps in the facility to ensure closing properly and are smoke tight.

Director of Maintenance / Designee will audit the doors monthly X3 for gaps and semi-annual to ensure substantial compliance.

Director Maintenance will report the findings to QAPI Committee to ensure substantial compliance.

Correction date will be completed by April 26, 2022






NFPA 101 STANDARD Sprinkler System - Installation: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.
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: NEW BUILDING - Component: 03 - Tag: 0351

Based on observation and interview, it was determined the facility failed to install and maintain the automatic sprinkler system in two locations, affecting one of one floor.

Findings include:

1. Observation on April 4, 2022, between 11:44 a.m. and 11:55 a.m., revealed the following:

a. 11:44 a.m., the soffit located at the exterior patio exit precludes the automatic sprinkler head from covering the entire area with automatic sprinkler protection.
b. 11:55 a.m., the 400 hallway exterior exit lacks automatic sprinkler protection.

Exit interview with the Facility Administrator and the Facilities Manager on April 4, 2022, between 12:30 p.m. and 12:40 p.m., confirmed the automatic sprinkler system deficiencies.



 Plan of Correction - To be completed: 04/26/2022

Tilley Fire Solutions was contacted on April 4th to have the sprinkler head replaced outside the 400 hallway and adjustments on the exterior patio.

All sprinkler heads will be checked to ensure that placement and adjustment to cover the area is protected.

Director of Maintenance / Designee will audit the sprinkler heads monthly X3 to ensure proper placement and semi-annual to ensure substantial compliance.

Director Maintenance will report the findings to QAPI Committee to ensure substantial compliance.

Correction date will be completed by April 26, 2022



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: NEW BUILDING - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of one floor.

Findings include:

1. Observation on April 4, 2022, at 12:02 p.m., revealed the administrator's office door was not smoke-tight.

Exit interview with the Facility Administrator and the Facilities Manager on April 4, 2022, between 12:30 p.m. and 12:40 p.m., confirmed the corridor opening deficiency.




 Plan of Correction - To be completed: 04/26/2022

The administrator office door has been adjusted to be smoke tight.

All doors were checked for gaps in the facility to ensure closing properly and are smoke tight

Director of Maintenance / Designee will audit the doors monthly X3 for gaps and semi-annual to ensure substantial compliance.

Director Maintenance will report the findings to QAPI Committee to ensure substantial compliance.

Correction date will be completed by April 26, 2022




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