Pennsylvania Department of Health
MEADOW VIEW NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MEADOW VIEW NURSING 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 March 11, 2024, at Meadow View Nursing 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 # 191702
Component 01
Main Building

Based on a Medicare/ Medicaid Recertification Survey completed on March 11, 2024, it was determined that Meadow View Nursing 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 (111), protected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

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 hazardous area enclosures in three instances, affecting two of sixteen smoke compartments.

Findings include:

1. Observation on March 11, 2024, revealed the facility failed to maintain the required one-hour fire rating in the following hazardous area enclosure locations:

a) 8:52 a.m., observation above the ceiling at the boiler room doors in the basement (maintenance office side) revealed multiple unsealed data wires in a conduit passing through the boiler room wall;
b) 8:56 a.m., observation above the ceiling by the break room in the basement revealed the facility used an unapproved sealant (spray foam) to seal a large drainpipe passing through the boiler room wall;
c) 10:33 a.m., the common office (admin-side) is larger than fifty square feet in size and is being used to store combustible storage (multiple boxes of medical records), the room does not meet the requirements for a hazardous area enclosure.

Interview with the Director of Admin Services and the Maintenance Director on March 11, 2024, at 1:45 p.m., confirmed the listed hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 04/24/2024

Unsealed penetrations will be sealed with a UL approved fire stop system. Maintenance staff will do random audits on unsealed wires and penetrations
Education will be provided to maintenance staff on importance of filling penetrations.
Monthly Audits X3 months on random Horizontal penetrations will be completed by Maintenance director or designee to ensure no new penetrations are present.
Any findings will be reported QAPI for review.

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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting four of sixteen smoke compartments.

Findings include:

1. Observation on March 11, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:04 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. The suspended ceiling in the central supply storage room on the first floor had multiple misaligned ceiling tiles leaving multiple unsealed gaps between the ceiling tiles;
b) 9:21 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the core supply room on the first floor;
c) 9:25 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. The suspended ceiling in the Level 1 A-side storage room on the first floor had multiple misaligned ceiling tiles leaving multiple unsealed gaps between the ceiling tiles;
d) 10:01 a.m., observation above the ceiling by the second window in the 2 C-hallway (stairwell end) revealed flexible ductwork laying on top of a sprinkler branch line in two locations.

Interview with the Director of Admin Services and the Maintenance Director on March 11, 2024, at 1:45 p.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/24/2024

Ceiling tile will be realigned in the 2 areas and Monthly Audits X3 months in random areas will be completed by the Maintenance director or designee. Maintenance staff will be educated on the importance of maintaining a smoke/heat resistive ceiling for proper operation. The results will be reported at the monthly QAPI meeting.

Supplies in the core supply room were removed and education was given to staff on storing of supplies above the line on the wall. Monthly audits x3 months will be completed by the Maintenance director or designee and reported at the monthly QAPI meeting.

The flexible ductwork was removed and ran under the sprinkler branch line in both locations. Monthly X3 months random audits will be completed by the Maintenance director or designee. Maintenance staff will be educated on the importance of no items being attached or laying on the sprinkler pipes. Results will be reported at the monthly QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Out of Service:

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.

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0354

Based on documentation review and interview, it was determined the facility failed to meet the requirements for a fire watch policy, for the automatic sprinkler system being out of service, affecting the entire facility. In accordance with NFPA 101, 9.7.6, and NFPA 25, 15.5.2(4)

Findings include:

1. Documentation review on March 11, 2024, at 12:50 p.m., revealed the facility failed to write and implement a fire watch policy that identifies procedures for the automatic sprinkler system being out of service for ten hours or more in a twenty-four-hour period.

Interview with the Director of Admin Services and the Maintenance Director on March 11, 2024, at 1:45 p.m., confirmed the facility failed to write and implement a fire watch policy that identifies the automatic sprinkler system out of service for ten hours or more in a twenty-four-hour period.

Plan of Correction - To be completed: 04/24/2024

A fire watch policy was reviewed and approved that identifies procedures for the automatic sprinkler system being out of service for 10 hours or more in a 24-hour period.

NFPA 101 STANDARD Corridor - Doors:

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 corridor doors in eight instances, affecting five of sixteen smoke compartments.

Findings include:

1. Observation on March 11, 2024, revealed the following corridor doors had large gaps at the top and side when fully closed and latched in their frame and could not resist the passage of smoke:

a) 9:26 a.m., resident room 112;
b) 9:31 a.m., resident room 114;
c) 9:37 a.m., resident room 202;
d) 9:46 a.m., level 2 nourishment room by the nurse station;
e) 9:48 a.m., resident room 218;
f) 9:49 a.m., resident room 226;
g) 11:11 a.m., resident room 328;
h) 11:12 a.m., resident room 330.

Interview with the Director of Admin Services and the Maintenance Director on March 11, 2024, at 1:45 p.m., confirmed the listed corridor door deficiencies.

Plan of Correction - To be completed: 04/24/2024

Adjustments and repairs will be made to the following doors 112,114,202,218,226,328,330 and level 2 nourishment room. The Maintenance director or designee will audit corridor doors to identify doors that are out of compliance. Results will be reported at the monthly QAPI meeting.

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