Pennsylvania Department of Health
EMBASSY OF TUNKHANNOCK
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EMBASSY OF TUNKHANNOCK - 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 29, 2024, at The Gardens at Tunkhannock, 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# 551002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2024, it was determined that The Gardens at Tunkhannock 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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area door openings in one location, affecting one of one floors.

Findings include:

1. Observation on May 29, 2024, at 11:49 a.m., revealed the Green Wing Dinette Room, had a storage room that lacked self-closing hardware. Stored within the room is (various holiday decorations, including artificial Christmas trees).

Interview at exit with the Administrator and Director of Maintenance on May 29, 2024, at 12:30 p.m., confirmed the door lacked self-closing hardware.

Plan of Correction - To be completed: 06/13/2024

1. Self closure hardware added to storage room door on 5/30/2024.
2. Audit of all storage room doors to ensure proper self closure hardware installed. No further discrepancies identified.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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, it was determined the facility failed to maintain the sprinkler system in one location, affecting one of one floors.

Findings include:

1. Observation and interview on May 29, 2024, at 11:40 a.m., revealed the sprinkler head, in the 1st Floor, Resident Room 101, was missing an escutcheon.

Interview at exit with the Administrator and Director of Maintenance on May 29, 2024, at 12:30 p.m., confirmed the missing escutcheon.

Plan of Correction - To be completed: 05/30/2024

1. Escutcheon added to sprinkler head in room 101 on 5/30/2024.
2. Audit of all sprinkler heads in facility identified no discrepancies.
3. Education provided to maintenance director and assistant on escutcheons.

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