Nursing Investigation Results -

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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT TUNKHANNOCK, THE
Inspection Results For:
There are 39 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


GARDENS AT TUNKHANNOCK, 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 May 25, 2022, 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 25, 2022, 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 Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signs, affecting two of seven smoke compartments.

Findings include:

1. Observation on May 25, 2022, between 10:00 a.m. and 10:45 a.m., revealed exit signs which were not illuminated at the following locations:

a. 10:00 a.m. - Service Wing Exit.
b. 10:45 a.m. - Blue Wing Exit.

Exit interview with the Facility DON and Facility Representative #1 on May 25, 2022, at 12:20 p.m., confirmed the exit signs were not lighted.

Plan of Correction - To be completed: 06/24/2022

1. Exit signs at Service wing exit and blue wing exit serviced and operational.
2. All exit signs in facility audited to ensure they are operational.
3. Education provided to maintenance staff on standard of maintaining exit sign illumination.
4. Daily rounds by maintenance director/designee of all exit signage to confirm compliance X 12 weeks. Results to be reviewed by QAPI committee.
5. 6/24/2022

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of approximately thirty fire extinguishers.

Findings include:

1. Observation on May 25, 2022, at 11:30 a.m., revealed the fire extinguisher located in the Dining room was blocked by a stationary chair.

Exit interview with the Facility DON and Facility Representative #1 on May 25, 2022, at 12:20 p.m., confirmed the blocked fire extinguisher.

Plan of Correction - To be completed: 06/24/2022

1. Stationary chair was immediately removed from corridor at time of inspection.
2. Nursing staff educated on not placing stationary objects including chairs in front of fire extinguishers on nursing units.
3. Daily audits of fire extinguishers to be completed by Mx director/designee X 12 weeks to ensure compliance with safety standard.
4. 6/24/2022

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting two of seven smoke compartments.

Findings include:

1. Observation on May 25, 2022, at 11:15 a.m., revealed unsealed penetrations in the Main Lobby smoke barrier wall.

Exit interview with the Facility DON and Facility Representative #1 on May 25, 2022, at 12:20 p.m., confirmed the penetrations.

Plan of Correction - To be completed: 06/24/2022

1. Smoke penetrations sealed by maintenance with approved sealant.
2. Maintenance director/designee will inspect smoke barriers when items are installed to prevent smoke barrier penetrations that are not sealed properly.
3. Random smoke barrier assessment will occur on daily audits by mx director/designee X 12 weeks. Results to be reviewed by QAPI committee to ensure compliance.
4. 6/24/2022

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