Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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VALLEY MANOR REHABILITATION AND HEALTHCARE 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 04, 2024, it was determined that Valley Manor Rehabilitation and Healthcare Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview it was determined that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated at least annually, for one of one plan.

Findings include:

Document review on March 4, 2024, at 10:00 a.m., revealed the facility lacked documentation indicating annual review of the Emergency Preparedness Plan.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/03/2024

1.The Emergency Preparedness Plan was reviewed and updated immediately.

2.Trends will be audited through QAPI to ensure the emergency preparedness plan is completed and updated annually.

Initial comments:Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0000

Facility ID# 480202
Component 01
Main Building (North & South Wings)

Based on a Medicare/Medicaid Recertification Survey conducted on March 4, 2024, it was determined that Valley Manor Rehabilitation and Healthcare Center 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 one story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress Capacity:

Means of Egress Capacity
The capacity of required means of egress is in accordance with 7.3.
18.2.3.1, 19.2.3.1

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0231

Based on observation and interview, it was determined the facility failed to maintain the minimum required clearances along the means of egress, affecting two of two levels.

Findings Include:

1. Observation on March 4, 2024, at 11:00 a.m., revealed the Northeast Stair Tower width was 33 in. The required width is 36 in.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the stair tower width.

2. Observation on March 4, 2024, at 10:50 am, revealed the Basement Level lacked acceptable headroom clearance along the exit access corridor. The headroom clearance was less than the required six feet, eight inches, (height was approximately six feet, six inches) from overhead sprinkler piping to finished floor level.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the headroom clearance.

Plan of Correction - To be completed: 04/03/2024

1. The facility is requesting that the DOH Division of Life Safety perform an updated FSES.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting two of four smoke compartments.

Findings include:

Observation on March 4, 2024, revealed the following deficiencies of rated hazardous area enclosures:

a. 10:50 a.m., the basement personal storage room door failed to close and latch.
c. 11:00 a.m., on the first floor, the dining room doors lacked self-closing devices, room currently being used as storage room.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the hazardous area deficiencies.

Plan of Correction - To be completed: 04/03/2024

1.The basement personal storage room door was repaired to fully close and latch. The dining room, which is currently being used for storage, is being returned to its original intended use as a dining room. The items being stored are being removed and stored elsewhere.

2.Current storage room areas were reviewed to ensure they fully close and latch.

3.Staff education completed on regulation for NFPA 101 Standard (section 8.4) stating that "doors shall be self-closing or automatic closing ".

4.To prevent recurrence, random facility audits will be completed weekly X 4 weeks; bi-weekly X 1 month and monthly X 1 month. Audit results will be reviewed monthly at QAPI.

5.Date of compliance is 4/3/24.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

This is a less serious (but not lowest level) 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 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.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.

Findings include:

1. Observation on March 4, 2024, at 9:30 a.m., revealed the January 18, 2024, fire alarm inspection report listed 4- deficiencies. Evidence of corrective action was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the fire alarm deficiencies.

2. Observation on March 4, 2024, at 11:00 a.m., revealed the facility fire alarm panel was in trouble mode at time of survey.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 04/03/2024

1. The facility received copies of the fire alarm inspection report and asked for quotes for the repairs. Once the quote is approved, the facility will schedule with the fire systems vendor to make necessary repairs. The fire alarm panel has been corrected and is no longer in trouble mode.

2.Inspection reports and corrective actions will be stored in a binder in an easily accessible area for review. The facility administrator will also receive a copy of the inspection report for review.

3.Staff education completed on regulation NFPA 70 National Electric Code and NFPA 72 National Fire Alarm and Signaling Code stating the records of system acceptance, maintenance and testing are readily available.

4.To prevent recurrence, the Inspection reports binder will be audited monthly X 3 months to ensure consistency on placement and review of repairs completed. Audit results will be reviewed at the monthly QAPI meeting.

5. Date of compliance is 4/3/2024.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0371

Based on observation, document review, and interview, it was determined the facility failed to provide adequate square footage of smoke compartments, affecting two of four smoke compartments.

Findings include:

Document review on March 4, 2024, at 10:45 a.m., revealed smoke compartments 400 wing (zone two) and the First Floor (zone three), Rooms 101-111 and 101-302, had zones exceeding 22,500 square feet.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the size of the smoke compartments were larger than the maximum square footage permitted.

Plan of Correction - To be completed: 04/03/2024

1. The facility is requesting that the DOH Division of Life Safety perform an updated FSES.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting one of two levels.

Findings include:

Document review on March 4, 2024, at 9:30 a.m., revealed the facility lacked documentation indicating a four-year exercise of the fire/smoke dampers was performed.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed damper inspection documentation was not available.

Plan of Correction - To be completed: 04/03/2024

1. The facility will contract and schedule with the fire alarms system vendor to complete the required 4 year testing of the fire dampers

2./3. Inspection reports and corrective actions will be stored in a binder in an easily accessible area for review. Staff education on inspection parameters and documentation.

4. To prevent recurrence, the Inspection reports binder will be audited monthly X 3 months to ensure consistency on placement and review of repairs completed. Audit results will be reviewed monthly at the QAPI meeting.

5. Date of compliance is 4/3/2024.

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: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of laundry chute rooms, affecting one of two levels.

Findings include:

Observation on March 4, 2024, at 12:00 p.m., revealed, on the first floor, the laundry chute door was propped open with cardboard.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the chute room door deficiency.

Plan of Correction - To be completed: 04/03/2024

1.The cardboard was removed from propping open the laundry chute door immediately.

2.Facility completed n audit to ensure doors are not being propped open.

3.Staff education completed on NFPA 101 Rubbish Chutes, Incinerators, and Laundry chutes. (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.

4. To prevent recurrence, the Director of Maintenance will complete audits weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month to ensure continuity with keeping the laundry chute door closed when not in use. Audit results will be reviewed monthly at the QAPI meeting.

5. Date of compliance is 4/3/2024.

NFPA 101 STANDARD Fire Drills:

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly for seven of twelve required drills.

Findings include:

Document review on March 4, 2024, at 9:30 a.m., revealed the facility could not provide documentation that fire drills had been conducted for the following times:

a. all quarters- second shift.
b. second, third, and fourth quarters- third shift.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the missing fire drills.

Plan of Correction - To be completed: 04/03/2024

1.The facility will conduct fire drills immediately on all three shifts. Going forward the facility will create a schedule for fire drills to ensure they are completed as required.

2./3. The Maintenance Director was educated on conducting the fire drills once per shift per quarter.

4. To prevent recurrence, the NHA or designee will complete audits weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month to ensure continuity with conducting fire drills according to regulation. Audit results will be reviewed monthly at the QAPI meeting.

5. Date of compliance is 4/3/2024.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels.

Findings include:

Observations on March 4, 2024, revealed the following electrical wiring deficiencies:

a. 11:00 a.m., basement boiler room electrical panel missing multiple protective blanks.
b. 11:05 a.m., basement sprinkler room, electrical panels LPX and HVP2 missing blanks.
c. 11:20 a.m., Fire Pump House, electrical panel missing multiple protective blanks.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 pm, confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.

Plan of Correction - To be completed: 04/03/2024

1. The basement boiler room electrical panel had protective blanks added where needed; the sprinkler room electrical panels LPX and HVP2 had protective blanks added where needed; the fire pump house electrical panel had protective blanks added where needed.

2. Facility electric panels were inspected for any missing blanks and if any other were found, protective blanks were added.

3. The maintenance team was educated on NFPA 70 for National Electric Code and NFPA 99.

4. To prevent recurrence, the NHA or designee will complete audits weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month to ensure continued compliance with NFPA 70 National Electric Code and NFPA 99. Audit results will be reviewed at monthly QAPI.

5. Date of compliance is 4/3/2024.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator.

Findings Include:

Document review on March 4, 2024, at 9:30 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items for the period of March 28- May 30, 2023:

a. weekly visual inspections.
b. monthly load testing.
c. monthly conductance testing of the generator battery.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/03/2024

1. The facility immediately conducted the required testing of the emergency generator.

2. Regular facility generator inspection schedules have been established to included weekly visual inspections; monthly load testing; and monthly conductance testing of the generator battery.

3. The maintenance team has been educated on NFPA Electrical systems- Essential Electric System Maintenance and testing.

4. To prevent recurrence, the NHA or designee will complete audits weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month to ensure continued compliance the generator inspection completion. Audit results will be reviewed monthly at QAPI.

5. Date of compliance is 4/3/2024.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of two levels.

Findings include:

Observation on March 4, 2024, at 10:55 a.m., revealed, a surge protector plugged into an extension cord, basement- housekeeping.

Exit Interview with the Administrator and Maintenance Director on March 4, 2024, at 12:45 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 04/03/2024

1.The surge protector was removed.

2.The facility has been inspected to ensure there is no other improper use of surge protectors.

3.The maintenance team has been educated on NFPA Electrical Equipment- Power Cords and Extension Cords Power strips and what qualifies as acceptable use of these devices.

4.To prevent recurrence, the NHA or designee will complete audits weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month to ensure continued compliance with use of Power Strips. Audit results will be reviewed monthly at QAPI.

5.Date of compliance is 4/3/2024.

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