Pennsylvania Department of Health
GARDENS AT WYOMING VALLEY, THE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT WYOMING VALLEY, THE
Inspection Results For:

There are  38 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 WYOMING VALLEY, 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 April 3, 2024, at The Gardens at Wyoming Valley, 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# 971402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 3, 2024, it was determined that The Gardens at Wyoming Valley 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 (111), protected, noncombustible building, with rooftop mechanical spaces, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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 in four locations, affecting two of three floors.

Findings include:

1. Observation on April 3, 2024, between 9:50 a.m., and 10:46 a.m., revealed the following:

a. 9:50 a.m., a damaged ceiling tile, located within the third floor, Personal Laundry.
b. 9:55 a.m., a speaker, located within the third floor, exit access corridor system, closest to Resident Room 313, lacked "bonnet" protection.
c. 9:58 a.m., a speaker, located within the third floor, exit access corridor system, closest to Resident Room 302, lacked "bonnet" protection.
d. 10:46 a.m., a penetration of the ceiling tile portion of the rated ceiling assembly, located within first floor Laundry.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the building construction deficiencies.



 Plan of Correction - To be completed: 05/21/2024

The ceiling tile in the 3rd floor personal laundry was replaced.
The speaker on the 3rd floor (by room 313) has been given "bonnet" protection.
The speaker on the 3rd floor (by room 302) has been given "bonnet" protection.
The ceiling tile in the 1st floor laundry room has been replaced.

No other areas were affected.

The maintenance director/designee will audit the 1st floor laundry room, 2nd floor personal laundry room, 3rd floor personal laundry room and the speakers to insure there are no penetrations and the bonnet protection is adequate (areas by rooms 302 and 313) 1x/month for 3 months.

The results of the audit will be presented to the QA committee for review and recommendations.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting two of three floors.

Findings include:

1. Observation on April 3, 2024, at 9:46 a.m., revealed a vertical penetration of the third floor, floor slab assembly, located within the duct chase, located within the Lounge.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the vertical opening deficiency.



 Plan of Correction - To be completed: 05/21/2024

The vertical penetration of the 3rd floor slab assembly has been repaired.

No other areas were affected.

The maintenance director/designee will audit the slab assembly 1x/month for 3
months.

The results of the audit will be presented to the QA committee for review and recommendations.


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting two of three floors.

Findings include:

1. Observation on April 3, 2024, between 9:37 a.m., and 10:41 a.m., revealed the following:

a., 9:37 a.m., the third floor, Penthouse level, Electrical Equipment Room door required adjustment to fully latch.
b. 10:41 a.m., the first floor, Central Supply Room door was held open by unapproved means (door chock).

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiencies.




 Plan of Correction - To be completed: 05/21/2024

The 3rd floor electrical equipment room door was adjusted to fully latch.

The central supply door was closed immediately, and the door chock removed.

The maintenance director/designee will in-service central supply clerk regarding the door chock and the propped door.

The maintenance director/designee will audit doors on the 1st, 2nd and 3rd floors 1x/week to insure there are no propped doors.

The results of the audit will be presented to the QA committee for review and recommendations.


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 documentation review and interview, it was determined the facility failed to maintain the building fire alarm system in one instance, affecting three of three floors.

Findings include:

1. Observation on April 3, 2024, at 11:03 a.m., revealed the facility lacked biennial sensitivty testing data of the building fire alarm system.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the fire alarm system deficiency.



 Plan of Correction - To be completed: 05/21/2024

The facility will have the biennial fire alarm sensitivity testing performed on May 20, 2024. The previous testing was performed on May 24, 2022.

The NHA/designee will in-service the maintenance director to ensure that the testing is performed every other year.

The results of the system test will be presented to the QA committee for review and recommendations.

NFPA 101 STANDARD Corridor - 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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of three floors.

Findings include:

1. Observation on April 3, 2024, between 9:44 a.m., and 10:44 a.m., revealed the following:

a. 9:44 a.m., the distance between the third floor, Sunroom doors exceeded one-eighth-inch.
b. 10:44 a.m., the first floor, Therapy Room doors required adjustment to fully latch one to another.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.




 Plan of Correction - To be completed: 05/21/2024

The distance between the 3rd floor sunroom doors has been adjusted to meet the NFPA standards.

The therapy room doors have been adjusted to positively latch.

No other doors were affected.

The maintenance director/designee will audit the doors adjusted (therapy room and 3rd floor electrical room) to ensure positive latching 1x/month for 3 months.

The results of the audit will be presented to the QA committee for review and recommendations.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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, in one location, affecting one of three floors.

Findings include:

1. Observation on April 3, 2024, at 9:52 a.m., revealed a penetration of the portion of the third floor smoke barrier separation wall, located above the smoke barrier doors, closest to the Spa.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the smoke barrier wall deficiency.



 Plan of Correction - To be completed: 05/21/2024

The penetration of the 3rd floor smoke barrier located above the smoke barrier doors (closest to the spa) has been sealed.

There are no other penetrations present near the area identified.

The maintenance director/designee will audit the 2nd and 3rd floor smoke barriers near the spa 1x/month for 3 months to ensure there are no other penetrations and the repair is effective.

The results of the audit will be presented to the QA committee for review and recommendations.

NFPA 101 STANDARD HVAC: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.
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 one location, affecting three of three floors.

Findings include:

1. Observation on April 3, 2024, at 11:10 a.m., revealed the fire damper report, dated 9/20/20-5/10/23, revealed fire dampers had been "cleaned" and "inspected," but did not specify that fusible links had been removed, and that fire dampers had been exercised.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the HVAC deficiency.



 Plan of Correction - To be completed: 05/21/2024

The damper report has been updated to include the documentation of the cleaning, inspection of fusible links and exercising the dampers.

The NHA/designee will in-service the maintenance director regarding the documentation requirements.

The maintenance director will continue to audit the dampers per the facility policy.

The results of the audit will be presented to the QA committee for review and recommendations.


NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain linen and rubbish chutes four instances, affecting two of three floors.

Findings include:

1. Observation on April 3, 2024, between 10:12 a.m., and 10:58 a.m., revealed the following:

a. 10:12 a.m., the third floor, rubbish chute door required adjustment to fully latch.
b. 10:21 a.m., the third floor, linen chute door lack positive latching hardware.
c. 10:57 a.m., the first floor, trash room chute door's 165 degree fusible link had been replaced with a wiring apparatus with which to hold the chute door in the "open" position.
d. 10:58 a.m., the first floor, Trash Termination Room door (interior) was held open by unapproved means (door chock).

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the linen and rubbish chute deficiencies.



 Plan of Correction - To be completed: 05/21/2024

The 3rd floor rubbish door latch has been adjusted. The 3rd floor linen chute door hardware has been fixed. The first-floor trash room chute door's fusible link is functioning. The wire apparatus has been removed. The chock has been removed in the 1st floor trash termination room.

The maintenance director/designee will in-service the staff regarding the chute doors being propped open and the door chocks being used to hold open doors.

The maintenance director/designee will audit the trash room chute door and the trash room interior door daily for 1 month then weekly for 2 months to ensure compliance.

The results of the audit will be presented to the QA committee for review and recommendations.

NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to maintain fire drills in one instance, affecting three of three floors.

Findings include:

1. Observation on April 3, 2024, at 11:00 a.m., revealed the facility lacked a first shift fire drill for the second quarter of calendar year 2023.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the fire drill deficiency.



 Plan of Correction - To be completed: 05/21/2024

The facility cannot correct the deficiency as it relates to the fire drill in 2023.

The maintenance director/designee will perform fire drills per NFPA regulations, and the corresponding documentation will be available.

The results of the drills will be presented to the QA committee for review and recommendations.


NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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.
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 the generator set in one instance, affecting three of three floors.

Findings include:

1. Observation on April 3, 2024, at 11:07 a.m., revealed the facility lacked documentation to support the required three year, four hour load bank testing of the generator set.

Exit interview on April 3, 2024, between 11:15 a.m., and 11:30 a.m., with the Facility Administrator and the Facilities Manager, confirmed the generator set deficiency.



 Plan of Correction - To be completed: 05/21/2024

The facility has documentation the 3-year, 4-hour generator load bank test was performed on July 20, 2023, from 2:00am-6:10am (4 hours and 10 min. or 300 minutes) on 100% load.

The NHA/designee will in-service the maintenance director regarding the 3-year test.

The results of the generator test will be presented to the QA committee for review and recommendations.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port