Pennsylvania Department of Health
SUNNYVIEW NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 40 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.


SUNNYVIEW NURSING AND REHABILITATION CENTER - 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 June 11, 2024, at Sunnyview 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 #970102
Component 01
Therapy Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2024, it was determined that Sunnyview Nursing and Rehabilitation Center 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 Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, the facility failed to meet fire alarm system maintenance and testing requirements for three of three building components.

Document review on June 11, 2024, at 9:30 a.m., revealed the facility failed to provide documentation for two-year sensitivity testing. The last documented testing occurred on October 9, 2021.

Interview with the administrator on June 11, 2024, at 9:30 a.m., confirmed the sensitivity test documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 08/02/2024

Two year sensitivity testing was completed on 6/4/2023 and is in place in the Life Safety Binder for future reference.

Monitoring of the Life Safety Binder will be completed monthly by the Environmental Director.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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, the facility failed to maintain smoke barrier partitions, affecting one of four building levels.

Findings include:

Observation on June 11, 2024, at 10:17 a.m., revealed the basement mechanical room S13 had ceiling tiles missing, which could allow smoke passage, possibly delaying the activation of the smoke detectors and/or sprinklers.

Interview with the maintenance technician, on June 11, 2024, at 10:17 a.m., confirmed the ceiling tile deficiency.

Plan of Correction - To be completed: 08/02/2024

Ceiling tiles will be replaced in the basement mechanical room to prevent smoke passage, possibly delaying the activation of the smoke detectors and/or sprinklers.

Monthly facility audits will be conducted to ensure ceiling tiles are in place.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on document review and interview, the facility failed to meet receptacle testing requirements for three of three building components.

Document review on June 11, 2024, at 9:22 a.m., revealed the annual receptacle documentation had the dates "5/10" and "5/16" written. However, the facility was unable to determine what year the receptacle testing occurred.

Interview with the administrator on June 11, 2024, at 9:22 a.m., confirmed the year of the annual receptacle testing was unavailable at the time of the survey.

Plan of Correction - To be completed: 08/02/2024

The receptacle testing dates were completed in 2024 and will have the year completed written on the document form to ensure compliance.

The forms will be audited upon completion by the NHA/designee to ensure compliance of the date written to include the year of completion.

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

Facility ID #970102
Component 02
Skilled Building and Intermediate Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2024, it was determined that Sunnyview Nursing and Rehabilitation Center 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 three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Discharge from Exits:

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0271

Based on observation and interview, the facility failed to maintain the discharge from exits in one of three building components.
Findings include:

Observation on June 11, 2024, between 10:02 a.m. and 10:10a.m., revealed the following exits failed to have a hard-packed, all-weather surface leading to a public way:
A. (10:02 a.m.) Sun room near the lobby;
B. (10:10 a.m.) Stair enclosure from the basement to the lobby emergency exit.

Interview with the director of nursing on June 11, 2024, at 10:10 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 08/02/2024

Bids are being secured to have all-weather surface leading to a public way from the below areas:
A. Sun room near the lobby;
B. Stair enclosure from the basement to the lobby emergency exit.

Environmental Director will coordinate the project and monitor for completion through to the end of the project.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0345

Based on document review and interview, the facility failed to meet fire alarm system maintenance and testing requirements for three of three building components.

Document review on June 11, 2024, at 9:30 a.m., revealed the facility failed to provide documentation for two-year sensitivity testing. The last documented testing occurred on October 9, 2021.

Interview with the administrator on June 11, 2024, at 9:30 a.m., confirmed the sensitivity test documentation was unavailable at the time of the survey.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, the facility failed to maintain sprinkler system maintenance and testing requirements in one of over four smoke compartments.
Findings include:

Observation on June 11, 2024, at 11:12 a.m., revealed kitchen walk-in freezer had a build-up of ice enclosing the sprinkler head, preventing it from functioning normally in an emergency.

Interview with the director of nursing on June 11, 2024, at 11:12 a.m., confirmed the sprinkler head was scheduled to be fixed.

Plan of Correction - To be completed: 08/02/2024

The built-up ice was removed from the sprinkler head to ensure proper function.

Education will be completed with the dietary department and maintenance will complete an audit of freezer checks to ensure there in no ice build-up.

NFPA 101 STANDARD Corridor - Doors:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0363

Based on observation and interview, the facility failed to maintain corridor doors for one of over seventy-five corridor doors.

Findings include:

Observation on June 11, 2024, at 10:39 a.m., revealed the first floor west wing resident room 115 door failed to positively latch in the frame.

Interview with the facility maintenance manager on June 11, 2024, at 10:39 a.m., confirmed the corridor door failed to latch.

Plan of Correction - To be completed: 08/02/2024

First floor west wing resident room 115 door was adjusted to ensure positive latch in the frame.

Weekly audits will be conducted for four weeks to ensure doors have positive latch.

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: BUILDING 02 - Component: 02 - Tag: 0372

Based on observation and interview, the facility failed to maintain the smoke barrier requirements on one of three building levels.

Findings include:

Observation on June 11, 2024, revealed the following smoke barrier deficiencies:
A. (10:01), Basement floor corridor near the electrical equipment room had an unsealed bulkhead, allowing smoke transfer into the interstitial space;
B. (10:05 a.m.), Basement level telephone room, inside the ancillary offices, had conduit and wires not sealed, allowing smoke transfer;
C. (10:20 a.m.), Basement level room #S-14, janitor closet, had plumbing penetrations through the deck above without sealant applied, allowing smoke transfer;
D. (10:23 a.m.), Basement trash room had ceiling tiles with gaps and misalignment in the grids and a lack of sealant around the chute stack, allowing smoke transfer.

Interview with the maintenance supervisor on June 11, 2024, at 10:23 a.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 08/02/2024

The below areas will be repaired with 3M fire barrier caulking.

A. Basement floor corridor near the electrical equipment room had an unsealed bulkhead, allowing smoke transfer into the interstitial space;
B. Basement level telephone room, inside the ancillary offices, had conduit and wires not sealed, allowing smoke transfer;
C. Basement level room #S-14, janitor closet, had plumbing penetrations through the deck above without sealant applied, allowing smoke transfer;
D. Basement trash room had ceiling tiles with gaps and misalignment in the grids and a lack of sealant around the chute stack, allowing smoke transfer.

Work orders will be generated for any further areas identified through the TELs system and monitored for completion by the Environmental Director.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0541

Based on observation and interview, the facility failed to maintain vertical door openings at one of eight vertical door openings.
Findings include:

Observation on June 11, 2024, at 9:56 a.m., revealed the basement level laundry chute door in the soiled laundry room lacked positive latching.

Interview with the maintenance director on June 11, 2024, at 9:56 a.m., confirmed the trash chute door lacked positive latching.

Plan of Correction - To be completed: 08/02/2024

Latch was adjusted to ensure positive latching.

All laundry chute doors will be inspected by the maintenance department for positive latching monthly during building rounds.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0912

Based on document review and interview, the facility failed to maintain receptacle testing requirements for three of three building components.

Document review on June 11, 2024, at 9:22 a.m., revealed the annual receptacle documentation had the dates "5/10" and "5/16" written. The facility was unable to determine what year the receptacle testing took place.

Interview with the administrator on June 11, 2024, at 9:22 a.m., confirmed the year of the annual receptacle testing was unavailable at the time of the survey.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000

Facility ID #970102
Component 04
Skilled Building and Intermediate Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2024, it was determined that Sunnyview Nursing and Rehabilitation Center 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 II (111), protected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0345

Based on document review and interview, the facility failed to meet fire alarm system maintenance and testing requirements for three of three building components.

Document review on June 11, 2024, at 9:30 a.m., revealed the facility failed to provide documentation for two-year sensitivity testing. The last documented testing occurred on October 9, 2021.

Interview with the administrator on June 11, 2024, at 9:30 a.m., confirmed the sensitivity test documentation was unavailable at the time of the survey.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0912

Based on document review and interview, the facility failed to meet receptacle testing requirements for three of three building components.

Document review on June 11, 2024, at 9:22 a.m., revealed the annual receptacle documentation had the dates "5/10" and "5/16" written. The facility was unable to determine what year the receptacle testing took place.

Interview with the administrator on June 11, 2024, at 9:22 a.m., confirmed the year of the annual receptacle testing was unavailable at the time of the survey.

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