Pennsylvania Department of Health
 PENNSWOOD VILLAGE
Building Inspection Results

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PENNSWOOD VILLAGE
Inspection Results For:

There are  59 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.
PENNSWOOD VILLAGE - 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 March 7, 2024, at Pennswood Village, 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 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0000


Facility ID# 164002
Component 01
Terrace Building, Preston Building, Woolman - Lower Level - Skilled Nursing, Barclay - Upper Level - Personal Care

Based on a Medicare/Medicaid Recertification survey completed on March 7, 2024, it was determined that Pennswood Village 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 II (222), fire resistive building, with a penthouse, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING 01 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of building separation walls, affecting one of two levels.

Findings include:

Observation on March 7, 2024, at 10:00 a.m., revealed on the Ground Floor, an open 3-inch conduit end above the fire barrier doors, between the Health Care and Mott Buildings.

Exit Interview with the Administrator and Facilities Director on March 7, 2024, at 11:45 a.m., confirmed the unsealed penetration.





 Plan of Correction - To be completed: 03/21/2024

- The facility does and shall continue to ensure common fire walls are maintained free of unsealed penetrations. Pennswood Village Facilities will seal holes and penetrations using through penetration fire stop system C-AJ-8255 products in the following area. Repair was made 3/21/2024.
- The Maintenance Manager/Designee will continue to conduct inspections on a quarterly basis to identify any penetrations of common fire walls and seal them with the required sealant. Results of ongoing inspections will be reported to the Quality Assurance Performance Improvement (QAPI) Team by the Maintenance Manager/Designee.
- Pennswood Village Maintenance Manager will oversee compliance.

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 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined that the facility failed to maintain hazardous areas, affecting one of two levels.

Findings include:

Observation on March 7, 2024, at 11:00 a.m., revealed the Enrichment Center electrical transformer room had multiple items stored within the room.

Exit Interview with the Administrator and Facilities Director on March 7, 2024, at 11:45 a.m., confirmed the storage in the hazardous electrical room.




 Plan of Correction - To be completed: 03/21/2024

- The facility does and shall continue to ensure that hazardous areas are maintained and that access to electrical panels and transformers are kept clear. Items stored in the Enrichment Center electrical transformer room were removed on March 7, 2024.
- The Maintenance Manager/Designee will continue to conduct weekly rounds to identify any areas with electrical panels or transformers and that items are not stored in or around those areas.
- Pennswood Village Maintenance Manager will oversee compliance.

NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain complete automatic sprinkler protection, affecting one of two levels.

Findings Include:

Observation on March 7, 2024, at 10:20 a.m., revealed a Ground Floor Physical Therapy closet lacked sprinkler protection.

Exit Interview with the Administrator and Facilities Director on March 7, 2024, at 11:45 a.m., confirmed incomplete sprinkler coverage.





 Plan of Correction - To be completed: 03/29/2024

- Keystone Fire and Security has been contracted to add a sprinkler head to the ground floor Physical Therapy closet on the morning of Tuesday, March 26 at 7:00 AM.
- The Maintenance Manager/Designee will continue to ensure that all inspections of the sprinkler system are thoroughly completed to meet requirements.
- Pennswood Village Maintenance Manger will oversee compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of two levels.

Observation on March 7, 2024, at 9:30 a.m., revealed, in the fire pump room, a sprinkler gauge was dated 2016, exceeding the 5-year service interval. Evidence of calibration was not available at time of survey.

Exit Interview with the Administrator and Facilities Director on March 7, 2024, at 11:45 a.m., confirmed the gauge was beyond the 5-year service interval.




 Plan of Correction - To be completed: 03/29/2024

- Keystone Fire and Security has been contracted to replaced and calibrate the sprinkler gauges in the fire pump room servicing the Health Center. This work will be completed on March 26, 2024.
- The Maintenance Manager/Designee will continue to ensure that all inspections of the sprinkler system are thoroughly completed to meet requirements.
- Pennswood Village Maintenance Manager will oversee compliance.

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 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two levels.

Findings include:

Observation on March 7, 2024, at 10:30 a.m., revealed, Ground Floor, above the smoke doors to Woolman West wing, an unsealed penetration around a data wire bundle.

Exit Interview with the Administrator and Facilities Director on March 7, 2024, at 11:45 a.m., confirmed the penetration.




 Plan of Correction - To be completed: 03/21/2024

- The facility does and shall continue to ensure common fire walls are maintained free of unsealed penetrations. Pennswood Village Facilities has sealed holes and penetrations using through penetration fire stop system C-AJ-8255 products in the following area:
- Woolman West wing, above smoke door.
- The Maintenance Manager/Designee will continue to conduct inspections on a quarterly basis to identify any penetrations of common fire walls and seal them with the required sealant. Results of ongoing inspections will be reported to the Quality Assurance Performance Improvement (QAPI) Team by the Maintenance Manager/Designee.
- Pennswood Village Maintenance Manager will oversee compliance.

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 (WOOLMAN & BARCLAY LEVELS) - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting one of two levels.

Findings include:

Document review on March 7, 2024, at 9:30 a.m., revealed the June 2023, Annual Fire Door Inspection report listed 2- fire doors as deficient. Evidence of corrective action was not available at time of survey.

Exit Interview with the Administrator and Facilities Director on March 7, 2024, at 11:45 a.m., confirmed the rated door deficiencies.




 Plan of Correction - To be completed: 03/22/2024

- The facility does and shall continue to ensure that all fire rated door openings are maintained. Pursuant to NFPA 80-2010 S.2.4.2 (8); NFPA 101-2012 18.3.6.3.5,19.3.6.3.5, activation of the fire alarm activates the latches to the doors leading from Woolman to the Mott building. Universal Door Services confirmed operation of the exit bars and latch upon inspection on February 23, 2024
- The Maintenance Manager/Designee will continue to oversee annual inspection of all fire doors by a certified contractor and monthly by a member of the Pennswood Maintenance Team. The Maintenance Manager/designee will report findings to the Quality Assurance Performance Improvement (QAPI) Team.
- Pennswood Village Maintenance Manager will oversee compliance.


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