Nursing Investigation Results -

Pennsylvania Department of Health
OAKWOOD HEIGHTS OF PRESBYTERIAN SENIORCARE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OAKWOOD HEIGHTS OF PRESBYTERIAN SENIORCARE
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

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OAKWOOD HEIGHTS OF PRESBYTERIAN SENIORCARE - 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 17, 2022, at Oakwood Heights of Presbyterian Seniorcare, 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 # 424402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 17, 2022, it was determined that Oakwood Heights of Presbyterian Seniorcare 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 three-story, Type II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain building construction height to meet regulations in all building areas.

Findings include:

Observation on May 17, 2022, at 8:45 a.m., revealed the facility exceeded the height requirements for a Type II (000) construction type.

Interview with the maintenance director on May 17, 2022, at 8:45 a.m., confirmed the facility exceeded the construction type height requirements.



 Plan of Correction - To be completed: 06/03/2022

The facility requests that the Department of Health Division of Life Safety conduct a new F.S.E.S.

The facility requests to continue the utilization of the existing Time-Limited Waiver for deficiency K0161.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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 meet requirements for sprinkler systems for one of over fifty rooms.

Findings include:

Observation on May 17, 2022, at 11:16 a.m., revealed the first floor kitchen had the following deficiencies:
A. (11:16 a.m.) Walk-in refrigerator had a sprinkler head leaking rusty water;
B. (11:16 a.m.) Walk-in freezer had a sprinkler head missing the escutcheon plate.

Interview with maintenance technician on May 17, 2022, at 11: 16 a.m., confirmed the above sprinkler system deficiencies, noting that these deficiencies were scheduled to be changed.



 Plan of Correction - To be completed: 06/01/2022

The sprinkler head and escutcheon plate were replaced by Absolute Fire Protection (contractor) on May 26-27, 2022.

A visual inspection of these sprinker components will be conducted monthly and tracked through the preventative maintenance software (WorxHub).
NFPA 101 STANDARD Electrical Systems - Wet Procedure Locations:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Electrical Systems - Wet Procedure Locations
Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection.
6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0913

Based on observation and interview, the facility failed to meet requirements for wet procedure locations for one of over twenty rooms.

Findings include:

Observation on May 17, 2022, at 10:05 a.m., revealed the second floor pantry room had an outlet not protected by a ground fault circuit interrupter (GFCI) within six feet of a water source.

Interview with maintenance technician on May 17, 2022, at 10:05 a.m., confirmed the above pantry room outlet was not protected by a GFCI.




 Plan of Correction - To be completed: 06/03/2022

The outlet was replaced with a an outlet protected by a ground fault circuit interrupter.

The maintenance director or designee will provide education to the maintenance staff regarding the proper maintenance of electrical wiring/components for wet procedure locations.

Any work being done by maintenance staff or outside contractors will be inspected by the maintenance director/designee upon completion of the work to ensure it is compliant with the life safety code standards.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916

Based on document review and interview, it was determined the facility failed to maintain essential electric system requirements for one of one generator.
Findings include:
Document review on May 17, 2022, at 9:12 a.m., revealed the facility was unable to provide documention that the annual fuel quality sample was completed in the last year.
Interview with the maintenance director on May 17, 2022, at 9:12 a.m., confirmed the above fuel quality sample was not provided at the time of the survey.



 Plan of Correction - To be completed: 06/06/2022

An analysis of the fuel quality sample from the emergency generator will be obtained and documentation kept on file.

Th annual fuel sample analysis will be added to WorxHub (preventative maintenance software) to ensure ongoing compliance.

The maintenance staff were educated on this requirement.

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