Pennsylvania Department of Health
NOTTINGHAM VILLAGE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 surveys for this facility. Please select a date to view the survey results.

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NOTTINGHAM VILLAGE - 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 January 16, 2024, at Nottingham Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID# 401002
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on January 16, 2024, it was determined that Nottingham Village 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 building, with partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Number of Exits - Story and Compartment:

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.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide required exiting, affecting one of ten smoke compartments

Findings include:

1. Observation on January 16, 2024, at 11:00 a.m., revealed the basement level lacked two acceptable means of egress.

Exit interview with the Director of Nursing and the Facilities Manager on January 16, 2024, between 11:40 a.m., and 11:50 a.m., confirmed the exiting deficiency.

Plan of Correction - To be completed: 03/10/2024

Nottingham Village is requesting DSI to re-evaluate the FSES

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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

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

Findings include:

1. Observation on January 16, 2024, between 10:22 a.m., and 10:53 a.m., revealed the following:

a. 10:22 a.m., the former Resident Room 139 room door lacked a self-closing device (presently used as storage).
b. 10:24 a.m., the former Resident Room 140 room door lacked a self-closing device (presently used as storage).
c. 10:32 a.m., the Side Two, Soiled Utility Room door was not smoke-tight.
d. 10:53 a.m., a louvered opening on the Unit Two, Storage Room door.

Exit interview with the Director of Nursing and the Facilities Manager on January 16, 2024, between 11:40 a.m., and 11:50 a.m., confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 03/10/2024

1. Room # 139 door now has a self-closing unit. Room # 140 now has a self-closing unit. Station #2 Soiled Utility Room Door is now smoke-tight. Station #2 storage room door has been adjusted.
2. Maintenance Director / designee will conduct facility sweep to identify other like hazardous enclosure issues.
3.NHA / Designee will educate Maintenance Staff on hazardous enclosures as it relates to storage.
4. NHA / Designee will conduct random inspections to confirm no other hazardous enclosure concerns continue, weekly X 4 weeks.

NFPA 101 STANDARD Corridor - Doors:

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 01 - Component: 01 - 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 January 16, 2024, at 11:01 a.m., revealed the Main Dietary entrance door was not smoke-tight.

Exit interview with the Director of Nursing and the Facilities Manager on January 16, 2024, between 11:40 a.m., and 11:50 a.m., confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 03/10/2024

1. Main Dietary entrance door is now smoke-tight.
2. Maintenance Director / Designee will inspect other doors leading into a corridor to validate no similar smoke -tight concerns exist.
3. NHA / Designee will educate maintenance staff on smoke-tight maintenance of corridor openings.
4. Maintenance Director / Designee will conduct random audits to validate corridor openings are maintained with smoke-tight door closures.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of one floor.

Findings include:

1. Observation on January 16, 2024, at 10:44 a.m., revealed the distance between the Side Two, smoke barrier separation doors, located closest to Supplies and Storage, exceeded one-eighth-inch.

Exit interview with the Director of Nursing and the Facilities Manager on January 16, 2024, between 11:40 a.m., and 11:50 a.m., confirmed the smoke barrier separation door deficiency.

Plan of Correction - To be completed: 03/10/2024

1. The distance between the double smoke doors on Station 2 back hall no longer exceed one-eight inch space.
2. Director of Maintenance / designee will inspect all double smoke doors in corridors to validate the gap between the doors does not exceed one-eighth inch.
3. NHA / Designee will educate maintenance staff on regulation K374 re: smoke barrier separation
4. Maintenance Director / Designee will conduct random inspections of all smoke barrier separation of corridor double doors weekly X 4 weeks.

Initial comments:Name: THERAPY ADDITION - Component: 03 - Tag: 0000

Facility ID# 401002
Component 03
Therapy Building

Based on a Medicare/Medicaid Recertification Survey completed on January 16, 2024, at Nottingham Village, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an exiting 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 building, that is fully sprinklered.

Plan of Correction:

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