Pennsylvania Department of Health
CANTERBURY PLACE
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
CANTERBURY PLACE
Inspection Results For:

There are  47 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.
CANTERBURY PLACE - 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 January 29, 2024, at Canterbury Place, 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# 050702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2024, it was determined that Canterbury Place 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 seven story, Type II (222), fire resistive structure, with a basement and penthouse, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223


Based on observation and interview, it was determined the facility failed to maintain the self-closing doors in one instance, affecting one of seventeen smoke compartments.

Findings include:

1. Observation on January 29, 2024, at 10: 36 a.m., revealed the door to the clean supply closet in the staff area on the first floor failed to latch when tested.

Interview with the Personal Care Administrator and Maintenance Director on January 29, 2024, at 12:30 p.m., confirmed the above listed self-closing door deficiency.



 Plan of Correction - To be completed: 03/15/2024

The door to the clean supply room now positively latches.
Maintenance staff will be re-educated on the importance of all doors positively latching.
Fifteen doors will be randomly selected weekly and monitored to ensure they positively latch. This will continue for a months' time and then the same frequency of audits will be completed on a bi-weekly basis.( see also K0363)
All data will be submitted to the QAPI committee for review. Any deficient practice will be immediately corrected. The committee will determine the need for any additional monitoring.

NFPA 101 STANDARD Corridor - Doors: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.
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 two instances, affecting one of seventeen smoke compartments.

Findings include:

1. Observation on January 29, 2024, revealed the following corridor door deficiencies:

a) 9:35 a.m., the door to room 211 on the second floor did not latch in its frame when tested;
b) 9:45 a.m., the door to room 206 on the second floor did not latch in its frame when tested.

Interview with the Personal Care Administrator and Maintenance Director on January 29, 2024, at 12:30 p.m., confirmed the corridor door deficiencies.





 Plan of Correction - To be completed: 03/15/2024

The doors to rooms 211 and 206 now positively latch.
Maintenance staff will be re-educated on the importance of all doors positively latching.
Fifteen doors will be randomly selected weekly and monitored to ensure they positively latch. This will continue for a months' time and then the same frequency of audits will be completed on a bi-weekly basis. (see also K0223)
All data will be submitted to the QAPI committee for review. Any deficient practice will be immediately corrected. The committee will determine the need for any additional monitoring.


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