Pennsylvania Department of Health
LECOM AT ELMWOOD GARDENS, LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LECOM AT ELMWOOD GARDENS, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Onsite Revisit to an Emergency Preparedness Survey completed on April 11, 2024, at Lecom at Elmwood Gardens, 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 #680202
Component 01
Main Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on April 11, 2024, it was determined that Lecom at Elmwood Gardens 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 two-story, Type III (200), unprotected, ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

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, the facility failed to maintain the proper fire resistance rating for a smoke barrier construction, affecting all smoke compartments.

Findings include:

Observation on April 11, 2024, at 9:45 a.m., revealed the facility had an FSES for incomplete smoke barriers.

Interview with the maintenance supervisor on April 11, 2024, at 9:45 a.m., confirmed the building had an FSES.

************************
Based on document review and interview during an Onsite Revisit Survey conducted on June 6, 2024, it was determined the facility had approved plans to drop the FSES for incomplete smoke barrier walls. Observation revealed there was new lighting installed in resident rooms that left penetrations in the smoke barrier wall.

Interview with the maintenance director on June 6, 2024, at 3:15 p.m., confirmed the facility had penetrations in the smoke barrier wall.

Plan of Correction - To be completed: 06/24/2024

The penetrations in the smoke barrier wall due to the new lighting will be sealed with an approved fire rated caulk and 5/8 inch drywall to maintain a ½ hour fire resistance rating and repair the penetrations.
The maintenance staff will be in-serviced on K 372 with an emphasis on smoke barrier penetrations.
The maintenance staff/designee will audit the facility to ensure no penetrations in smoke barrier walls and report any concerns to the Quality Assurance Performance improvement committee.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #680202
Component 02
Building 02

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on April 11, 2024, it was determined that Lecom at Elmwood Gardens 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, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0372

Based on observation and interview, the facility failed to maintain the proper fire resistance rating for a smoke barrier construction, affecting all smoke compartments.

Findings include:

Observation on April 11, 2024, at 9:45 a.m., revealed the facility had an FSES for incomplete smoke barriers.

Interview with the maintenance supervisor on April 11, 2024, at 9:45 a.m., confirmed the building had an FSES.

************************
Based on document review and interview during an Onsite Revisit Survey conducted on June 6, 2024, it was determined the facility had approved plans to drop the FSES for incomplete smoke barrier walls. Observation revealed there was new lighting installed in resident rooms that left penetrations in the smoke barrier wall.

Interview with the maintenance director on June 6, 2024, at 3:15 p.m., confirmed the facility had penetrations in the smoke barrier wall.

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