Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT ORANGEVILLE, THE
Inspection Results For:

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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 March 11, 2020, it was determined that The Gardens at Orangeville was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73 REQUIREMENT Establishment of the Emergency Program (EP):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.
The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:

*[For hospitals at 482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

*[For CAHs at 485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
Observations:
Name: - Component: -- - Tag: 0001

Based on documentation review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility.

Findings include:

1. Review of documentation on March 11, 2020, between 9:45 a.m. and 10:00 a.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 483.73, to include the following standards:

(a) Emergency Plan
(b) Policies and Procedures
(c) Communication Plan
(d) Training and Testing
(e) Emergency and Standby Power Systems


Exit interview with the facility administrator and the facilities manager on March 11, 2020, between 10:15 a.m. and 10:30 a.m., confirmed the emergency preparedness deficiencies.









 Plan of Correction - To be completed: 04/30/2020

The facility will establish and maintain a comprehensive emergency preparedness program to include all standards.
Program will be will be ta the QAPI committee


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 March 11, 2020, at The Gardens at Orangeville, it was determined there were no deficiencies identified under the 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:


Initial comments:Name: PT/OT BUILDING - Component: 02 - Tag: 0000

Facility ID# 379502
Component 02
PT/OT Building

Based on a Medicare/Medicaid Recertification Survey completed on March 11, 2020, at The Gardens at Orangeville, it was determined there were no deficiencies identified under the 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:


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 March 11, 2020, it was determined that The Gardens at Orangeville as 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 corridor opening, affecting one of one floor.

Findings include:

1. Observation on March 11, 2020, at 9:12 a.m., revealed the dietary department door required adjustment to fully latch.

Exit interview with the facility administrator and the facilities manager on March 11, 2020, between 10:15 a.m. and 10:30 a.m., confirmed the corridor opening deficiency.




 Plan of Correction - To be completed: 04/30/2020

Dietary Department door was immediately adjusted to fully latch
All doors were inspected to ensure fully operational
Audit of all doors will be completed to ensure fully operational 2 x a month x 2 months then monthly with results to QAPI committee for review and recommendation

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