Pennsylvania Department of Health
GARDEN SPRING NURSING AND REHABILITATION CENTER
Building Inspection Results

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GARDEN SPRING NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  49 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.
GARDEN SPRING NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on a Revisit to an Emergency Preparedness Survey completed on November 27, 2023, at Garden Springs Nursing And Rehabilitation Center 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# 860202
Component 01

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on November 27, 2023, it was determined that Garden Spring Nursing And Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on observation and interview, it was determined the facility failed to ensure rated door assemblies were maintained, affecting one of two floors.

Findings include:

Document review on November 27, 2023, at 9:00 a.m., revealed the Annual rated door inspection report listed- 9 rated door deficiencies, which remained uncorrected at the time of survey.

Exit interview with the Administrator and Director of Maintenance on November 27, 2023, at 12:45 p.m., confirmed the rated door deficiencies.

***************
Observation during an onsite Revisit conducted on January 23, 2024, between 10:00 a.m. and 11:45 a.m., determined the following:

Item 1 - Not Completed. The Annual rated door inspection report deficiencies remained uncorrected at time of Revisit.

Exit Interview with the Administrator and Maintenance Director on January 23, 2024, at 11:45 a.m., confirmed the above item was not completed.










 Plan of Correction - To be completed: 02/22/2024

Repairs to the 9 doors that failed the annual door inspection will be corrected. The facility has requested and submitted a Time Limited Waiver for some of these doors that will need to be replaced due to manufacture timeliness. The amount of time requested was 6/6/24.

The maintenance staff will be in serviced on completing timely repairs to the fire doors as they occur in the future.

The Director of Maintenance or designee will audit timely repairs to fire doors monthly times three.

Results of the audits will be reviewed by the QAPI Committee for recommendations.
NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance Pr:This is a less serious (but not lowest level) 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 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.
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0907

Based on observation and interview, it was determined the facility failed to maintain the medical gas system, affecting one of one medical gas system.

Findings include:

Observation on November 27, 2023, at 10:50 a.m., revealed the medical gas vacuum pump panel displayed the following trouble message: " Vacuum Xmitter has failed " .

Proof of corrective action was not available at time of survey.

Exit interview with the Administrator and Director of Maintenance on November 27, 2023, at 12:45 p.m., confirmed the medical gas deficiency.

***************
Observation during an onsite Revisit conducted on January 23, 2024, between 10:00 a.m. and 11:45 a.m., determined the following:

Item 1 - Not Completed. The medical gas vacuum pump panel displayed the following trouble message: " Vacuum Xmitter has failed " at time of revisit.

Exit Interview with the Administrator and Maintenance Director on January 23, 2024, at 11:45 a.m., confirmed the above item was not completed.








 Plan of Correction - To be completed: 02/22/2024

The part needed to repair the medical gas vacuum pump is on order. Once the part arrives the vendor will install and repair the medical gas vacuum pump.

The maintenance staff will be in serviced on the operation of the medical gas vacuum pump.

The Director of Maintenance or designee will audit to ensure the proper operation of the medical gas vacuum pump monthly times three.

Results of audits will be reviewed by QAPI Committee for recommendations.

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