Pennsylvania Department of Health
GARDENS AT ORANGEVILLE, THE
Building Inspection Results

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GARDENS AT ORANGEVILLE, THE
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT ORANGEVILLE, 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 14, 2024, at The Gardens at Orangeville, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID# 379502
Component 01
West Building

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2024, it was determined that The Gardens at Orangeville 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 II (000), unprotected, noncombustible building, that 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: WEST BUILDING - Component: 01 - 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 February 14, 2024, at 11:01 a.m., revealed the former Classroom door lacked a self-closing device (converted to storage room).

Exit interview on February 14, 2024, between 12:00 p.m., and 12:10 p.m., with Facility Representative One, and Facility Representative Two, confirmed the hazardous area enclosure deficiency.



 Plan of Correction - To be completed: 03/12/2024

The hazardous enclosure to the former classroom which was converted to a storage area in addition to classroom space, which is over 50 square feet, will have a self-closure device installed on the corridor door.
Anytime a location in the facility is changed/added to, the requirement will be reviewed for door closure and adapted as needed.
Initial comments:Name: PT/OT BUILDING - Component: 02 - Tag: 0000


Facility ID# 379502
Component 02
Therapy Building

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2024, it was determined that The Gardens at Orangeville 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 building, that is fully sprinklered.




 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: PT/OT BUILDING - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress in one location, affecting one of one floor.

Findings include:

1. Observation on February 14, 2024, at 11:29 a.m., revealed the breezeway exit discharge location was unplowed between the walkway and the parking lot.

Exit interview on February 14, 2024, between 12:00 p.m., and 12:10 p.m., with Facility Representative One, and Facility Representative Two, confirmed the means of egress deficiency.



 Plan of Correction - To be completed: 03/12/2024

All means of egress will be kept open at all times during inclement weather conditions. All exit, walkways and exit discharge locations of the facility will be monitored after the snow plowing is completed to ensure clear pathways. Results to QAPI for review and recommendations.
Initial comments:Name: EAST BUILDING - Component: 03 - Tag: 0000


Facility ID# 379502
Component 03
East Building

Based on a Medicare/Medicaid Recertification Survey completed on February 14, 2024, it was determined that The Gardens at Orangeville 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 II (000), unprotected, noncombustible building, that is fully sprinklered.



 Plan of Correction:


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: EAST BUILDING - Component: 03 - Tag: 0363

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 February 14, 2024, at 11:40 a.m., revealed the Resident Room 103 door was not smoke-tight.

Exit interview on February 14, 2024, between 12:00 p.m., and 12:10 p.m., with Facility Representative One, and Facility Representative Two, confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 03/12/2024

Resident room corridor door will be sealed to resist the passage of smoke. All corridor doors will be checked at this time. All corridor doors in the facility will be inspected and adjusted as needed monthly with results to QAPI for review and recommendations.

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