Pennsylvania Department of Health
MARYWOOD HEIGHTS
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MARYWOOD HEIGHTS - 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 July 8, 2024, at Marywood Heights, 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# 860302
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on July 8, 2024, it was determined that Marywood Heights 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 483.70(a).

This is a three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.

Findings include:

The facility failed to secure State-approved plans for the installation of the 100KW, natural gas generator set, located within the basement.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 08/30/2024

Review of facility generator paperwork/documentation reveals the generator was installed in October 2003 under previous ownership. Unable to locate State-approved plans for the installation. The facility will contact Plan Review for direction and follow through on any recommendations.

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain two common walls, in two locations, affecting two of four floors.

Findings include:

1. Observation on July 8, 2024, between 10:44 a.m., and 11:48 a.m., revealed the following:

a. 10:44 a.m., the third floor, common wall, required an intumescent seal on the Business Office side of the wall, running horizontally, between gypsum board and roof decking.
b. 11:48 a.m., the common wall door frame, located at the first floor, Apartment Building entrance, lacked fire-rated door frame labeling.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the common wall deficiencies.

Plan of Correction - To be completed: 08/30/2024

The intumescent seal on the Business Office side of the wall, running horizontally, between gypsum board and roof decking will be sealed with fire stop caulk.
The common wall door frame, located at the First Floor, Apartment Budling entrance, will be inspected to obtain certification letter and label for on the door frame.

NFPA 101 STANDARD Building Construction Type and Height:

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, it was determined the facility failed to maintain building construction requirements on three of three floors.

Findings include:

1. Observation on July 8, 2024, at 11:00 a.m., revealed the facility exceeded the maximum allowable story height for this type of construction.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the facility exceeded the maximum allowable story height for this type of construction.

Plan of Correction - To be completed: 08/30/2024

In July 2019, the facility was reclassified as a three-story structure with an attic space and basement. The facility is requesting a Time Limited Waiver to have a new FSES completed by a Life Safety.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain two stair tower enclosures in two locations, affecting four of four floors.

Findings include:

1. Observation on July 8, 2024, between 10:19 a.m., and 10:31 a.m., revealed the following:

a. 10:19 a.m., a large ladder was located within the basement-level portion of the rear stair tower enclosure.
b. 10:31 a.m., a trash receptacle was located within the basement-level portion of the front stair tower enclosure.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the stair tower enclosure deficiencies.

Plan of Correction - To be completed: 08/30/2024

The ladder and trash receptacle were removed from the stair tower enclosure. Maintenance staff was re-educated on the importance of having stair tower enclosures fee of any objects. The NHA/designee will conduct weekly audits for compliance and present findings to the QA committee for review and recommendations.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting, affecting four of four floors.

Findings include:

1. Observation on July 8, 2024, at 12:32 p.m., revealed the facility lacked documentation to support required monthly, thirty second testing of the battery-operated lighting fixture, located at the generator set, within the basement (ninety minute, yearly testing requirements met, and recorder during extended power outage on 6/27/2024).

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the emergency lighting deficiency.

Plan of Correction - To be completed: 08/30/2024

Maintenance staff will perform required monthly thirty second testing of the battery-operated lighting fixture located at the generator set. The NHA/designee will conduct monthly audits for compliance and present findings to the QA Committee for review and recommendations.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of four floors.

Findings include:

1. Observation on July 8, 2024, at 12:16 p.m., revealed the facility lacked one of two required kitchen exhaust hood duct cleaning receipts for the previous year (hood was cleaned on 3/25/24).

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the cooking facilities.

Plan of Correction - To be completed: 08/30/2024

The second kitchen hood duct cleaning is scheduled for August, 2024. Receipt will be obtained and logged. The NHA/designee will conduct biannual audits for compliance and present findings to the QA Committee for review and recommendations.

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, interview, and documentation review, it was determined the facility failed to maintain the automatic sprinkler system in multiple instances, affecting four of four floors.

Findings include:

1. Observation on July 8, 2024, between 10:12 a.m., and 11:58 a.m., revealed the following:

a. 10:12 a.m., a missing escutcheon plate, located within the basement-level, Elevator Machine Room.
b. 10:13 a.m., a missing escutcheon plate, located within the basement-level, Janitor's Closet.
c. 10:14 a.m., lint buildup, located on several sprinkler head assemblies, within the basement-level, Laundry.
d. 10:55 a.m., two missing escutcheon plates, located within the third floor, sitting area.
e. 11:22 a.m., several missing escutcheon plates, located within the second floor, sitting area.
f. 11:55 a.m., the facility lacked an annual main drain test, as well as annual control valve testing.
g. 11:58 a.m., the facility lacked required five-year, internal valve and internal pipe inspections.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/30/2024

The missing escutcheon plates in the basement Elevator Machine Room, Janitor's Closet, Second and Third Floor sitting areas will be replaced. Sprinkler head assemblies, within the laundry area, will be inspected for lint buildup and cleaned as needed. The annual main drain test and annual control valve testing will be completed. The required five-year internal valve and internal pipe inspection will be completed.

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 one smoke barrier separation wall, affecting one of four floors.

Findings include:

1. Observation on July 8, 2024, at 10:44 a.m., revealed the portion of the third floor smoke barrier separation wall, located closest to Resident Room 366, exhibited multiple penetrations, and horizontal gap between gypsum board and roof assembly (located above the smoke barrier doors).

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the smoke barrier wall deficiency.

Plan of Correction - To be completed: 08/30/2024

The unsealed penetrations on the Third Floor, located closest to Resident room 366 have been sealed with fire stop caulk. The Director of Facilities will conduct quarterly audits for compliance and present findings to the QA committee for review and recommendations.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning in multiple locations, affecting four of four floors.

Findings include:

1. Observation on July 8, 2024, at 12:13 p.m., revealed the facility lacked current fire damper preventative maintenance documentation (documentation dated 4/29/19).

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the HVAC deficiencies.

Plan of Correction - To be completed: 08/30/2024

521 Fire Damper Inspection will be completed. Vendor will provide a copy of his finding to include
preventative maintenance documentation.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain electrical receptacles in multiple locations, affecting three of four floors.

Findings include:

1. Observation on July 8, 2024, at 12:19 p.m., revealed required yearly receptacle testing had not been performed since March of 2023.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the electrical testing deficiency.

Plan of Correction - To be completed: 08/30/2024

Maintenance staff will perform required annual receptacle testing for receptacles at Resident bed locations. All results will be recorded. The NHA/designee will conduct annual audits for compliance and present findings to the QA committee for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in several instances, affecting four of four floors.

Findings include:

1. Observation on July 8, 2024, between 12:20 p.m., and 12:25 p.m., revealed the following:

a. 12:20 p.m., the facility lacked a natural gas reliability letter.
b. 12:21 p.m., the facility lacked recorded, weekly, generator set, visual inspection documentation.
c. 12:22 p.m., the facility lacked recorded, weekly, generator set, battery Electrolyte or Battery Voltage readings.
d. 12:25 p.m., the facility lacked recorded, monthly, generator set, load testing data.
e. 12:29 p.m., the generator set emergency stop button was located within the same enclosure (room) as the generator set.

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the generator set deficiencies.

Plan of Correction - To be completed: 08/30/2024

The facility will obtain a natural gas reliability letter from the supplier. Weekly generator set will include visual inspection documentation, battery voltage readings and load testing data. The facility will have the emergency stop button relocated out of the generator room.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain one oxygen cylinder storage location, affecting one of four floors.

Findings include:

1. Observation on July 8, 2024, at 11:12 a.m., revealed the second floor, oxygen cylinder storage room door lacked signage, readable from five feet that stated: "CAUTION, OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING."

Exit interview with the Facility Administrator on July 8, 2024, between 12:45 p.m., and 1:05 p.m., confirmed the oxygen cylinder storage room deficiency.

Plan of Correction - To be completed: 08/30/2024

A precautionary sign readable from five feet away was placed on the Second and Third Floors cylinder storage room stating, "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." The NHA/designee will conduct monthly audits for compliance and present findings to the QA Committee for review and recommendations.

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