Nursing Investigation Results -

Pennsylvania Department of Health
STONERIDGE TOWNE CENTRE
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
STONERIDGE TOWNE CENTRE
Inspection Results For:

There are  34 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.
STONERIDGE TOWNE CENTRE - 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 May 21, 2019, it was determined that Stoneridge Towne Centre had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients: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.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, it was determined the facility failed to share the facilities' emergency preparedness plan with resident's families or representatives, which serves the entire facility.

Findings include:

1. Review of documentation on May 21, 2019, at 9:00 AM revealed the facility lacked documentation verifying the facility had shared the facilities' Emergency Preparedness information with residents' families or representatives.

Interview with the Director of Nursing on May 21, 2019, at 9:00 AM confirmed the facility lacked documentation verifying the facility had shared the facilities' Emergency Preparedness information with residents' families or representatives.




 Plan of Correction - To be completed: 07/05/2019

This Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. This plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal requirements.

0035

Stoneridge Towne Centre has developed an Emergency Preparedness Plan. However, the facility has failed to document the effective communication to resident families or representatives. In response, the facility shall:

1. With admission information shall be included an Emergency Preparedness Plan Informational fact sheet. This will provide an overview and direction for addition resource information.

2. An informational letter from Administrator shall be sent to all responsible parties describing the EPP.

3. Verifying documentation shall be maintained that residents and responsible parties were informed of the EPP.

4. The effectiveness of the sharing of information from the EPP shall be reviewed during Quarterly QAPI meeting for review and recommendation.

Initial comments:Name: WCC - Component: 01 - Tag: 0000


Facility ID # 051102
Component 01
Warfel Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2019, it was determined that Stoneridge Towne Centre 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 four-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: WCC - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to test and clean the carbon monoxide detectors, per manufacturers recommendations and PA Act 45, in one of one buildings.

Findings include:

1. Review of documentation on May 21, 2019, at 8:15 AM revealed, at the time of survey, the facility lacked documentation verifying the carbon monoxide detectors had been cleaned and tested within the previous twelve months.

Interview with the Interim VP Environmental Services on May 21, 2019, at 8:15 AM confirmed the facility lacked documentation verifying the carbon monoxide detectors had been cleaned and tested within the previous twelve months.



 Plan of Correction - To be completed: 07/05/2019

0100

1. All Carbon Monoxide detectors have now been tested and cleaned.

2. Documentation shall be maintained in a log as part of the preventative maintenance program.

3. Administrator/designee shall educate the maintenance team on the requirement to test and clean carbon monoxide detectors in accordance with manufacturer recommendations and PA Act 45.

4. Test results shall be reported in QAPI meeting for review and recommendation.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: WCC - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairwell frame labels to be legible, on three of four levels within the component.

Findings include:

1. Observation on May 21, 2019, between 12:50 PM and 2:00 PM, revealed stairwell door frame labels were not legible, at the following locations:

a. 12:50 PM, 2nd floor stairwell, across from the West Elevator;
b. 1:23 PM, 2nd floor stairwell, across from Room 218;
c. 1:40 PM, 4th floor, West stairwell;
d. 1:50 PM, 4th floor, East stairwell;
e. 2:00 PM, ground floor, East stairwell.

Interview with the Interim VP Environmental Services on May 21, 2019, at 2:00 PM confirmed the stairwell door frames lacked readily legible UL approved labels.




 Plan of Correction - To be completed: 07/05/2019

0225

1. A, B, C, D, & Ё area labels have been addressed and are now legible.

2. Stair tower door frames for the remainder of the facility shall be checked for legible labels and corrected as needed.

3. Stair tower door frame labels shall be checked quarterly for next two quarters for legible labels.

4. Results to be shared at quarterly QAPI meeting.

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: WCC - Component: 01 - Tag: 0345

Based on document review, observation and interview, it was determined the facility failed to address deficiencies noted on the annual fire alarm report, and smoke detectors were not properly mounted to their housing, which serves the entire component.

Findings include:

1. Review of documentation on May 21, 2019, at 9:15 AM revealed the Simplex Fire Alarm Test Report, dated April 2019, indicated five smoke detectors were out of sensitivity range, LED was inoperative in Resident Room 407 & broken housing in the Resident Laundry.

Interview with the Interim VP Environmental Services on May 21, 2019, at 9:15 AM confirmed the deficiencies had not been corrected, at the time of survey.


2. Observation on May 21, 2019, between 1:25 PM and 1:30 PM revealed the following smoke detectors were hanging, unsecured, from the ceiling assembly:

a. 1:25 PM, 3rd floor by Room 310;
b. 1:30 PM, 3rd floor by the West Elevator.

Interview with the Interim VP of Environmental Services on May 21, 2019, at 1:30 PM confirmed the smoke detectors were unsecured, hanging from the ceiling assembly.





 Plan of Correction - To be completed: 07/05/2019

0345

1. The deficiencies noted on the Annual Simplex Fire Alarm Test Report listing the five smoke detectors, inoperative LED in Resident Room 407, and broken housing in Resident Laundry
have been fixed, as well as the hanging smoke detectors in Room 310 and 3rd floor by West Elevator.

2. The Maintenance Department shall be educated by the Administrator/designee as to the necessity to efficiently respond to the deficiencies stated in the Annual Simplex Fire Alarm Test Report.

3. Annual Simplex Fire Alarm Test Report shall be shared with the QAPI Committee for review and recommendation.

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: WCC - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to inspect and maintain corridor doors to positively latch, on one of more than fifty corridor doors within the component.

Findings include:

1. Observation on May 21, 2019, at 1:00 PM revealed Room 207 corridor door failed to close and positively latch in the frame.

Interview with the Interim VP Environmental Services on May 21, 2019, at 1:00 PM confirmed the door failed to positively latch.



 Plan of Correction - To be completed: 07/05/2019

0363

1. Corridor Door to Room 207 has been adjusted and now positively latches.

2. All other Corridor doors in the Component shall be checked for proper latching by maintenance, and adjustments made as needed to ensure positive latching of all corridor doors.

3. Corridor doors in the Component shall be checked for positive latching monthly for three months.

4. Results of the Corridor Door Checks shall be reviewed at the Quarterly QAPI meetings.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: WCC - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to secure medical gas cylinders, on one of four levels within the component.

Findings include:

1. Observation on May 21, 2019, at 1:17 PM revealed the 2nd floor Oxygen Storage Room had two unsecured oxygen cylinders sitting on the floor.

Interview with the Interim VP Environmental Services on May 21, 2019, at 1:17 PM confirmed there were unsecured oxygen cylinders.



 Plan of Correction - To be completed: 07/05/2019

0923

1. The unsecured O2 cylinders were secured on May 21, 2019. All rooms have since been checked by maintenance for unsecured O2 cylinders.

2. Nursing staff shall be educated by the DON/designee to the requirements of Oxygen storage, including securing all canisters in their proper rooms, with proper signage and in their proper secured racks according to empty or not empty.

3. Weekly rounds for 8 weeks shall be done by the DON/designee to ensure cylinders are properly secured.

4. Results of rounds shall be reported to the QAPI Committee for review and recommendation.



Initial comments:Name: HCC - Component: 02 - Tag: 0000


Facility ID # 051102
Component 02
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2019, it was determined that Stoneridge Towne Centre 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 four-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: HCC - Component: 02 - Tag: 0100

Based on document review and interview, it was determined the facility failed to test and clean the carbon monoxide detectors, per manufacturers recommendations and PA Act 45, in one of one buildings.

Findings include:

1. Review of documentation on May 21, 2019, at 8:15 AM revealed, at the time of survey, the facility lacked documentation verifying the carbon monoxide detectors had been cleaned and tested within the previous twelve months.

Interview with the Interim VP Environmental Services on May 21, 2019, at 8:15 AM confirmed the facility lacked documentation verifying the carbon monoxide detectors had been cleaned and tested within the previous twelve months.


 Plan of Correction - To be completed: 07/05/2019

0100

1. All Carbon Monoxide detectors have now been tested and cleaned.

2. Documentation shall be maintained in a log as part of the preventative maintenance program.

3. Administrator/designee shall educate the maintenance team on the requirement to test and clean carbon monoxide detectors in accordance with manufacturer recommendations and PA Act 45.

4. Test results shall be reported in QAPI meeting for review and recommendation

NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: HCC - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to continuously maintain the path of egress free of obstructions, on three of four levels within the component.

Findings include:

1. Observation on May 21, 2019 between 11:20 AM and 12:25 PM revealed furniture in the path of egress, which was not secured to the floor or wall, in the exit corridors, which would obstructed the path of egress in the following locations:

a. 11:20 AM, 3rd floor by Room 307;
b. 11:55 AM, 2nd floor by Room 207;
c. 12:25 PM, 1st floor by Room 107.

Interview with the Interim VP Environmental Services on May 21, 2019 at 12:25 PM confirmed the unsecured furniture located in the paths of egress.



 Plan of Correction - To be completed: 07/05/2019

0211

1. Areas a, b, & c that failed to maintain an egress free of obstructions have been corrected.

2. Maintenance Director/designee shall monitor during weekly environmental rounds for 8 weeks paths of egress to ensure they are free of obstructions.

3. The Interdisciplinary Management Team shall be educated by the Administrator regarding requirement of maintaining paths of egress that are free of obstructions.

4. Weekly rounding results to be shared with the QAPI Committee for review and recommendation.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: HCC - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower door frame labels to be legible, on three of four levels within the component.

Findings include:

1. Observation on May 21, 2019, between 11:40 AM and 12:25 PM revealed stairtower door frame labels were not legible, at the following locations:

a. 11:40 AM, 2nd floor, stairtower by the Nurses' Station;
b. 12:00 PM, 2nd floor, stairtower by Room 207;
c. 12:20 PM, 1st floor, stairtower by the connecting corridor and Nurses' Station;
d. 12:25 PM, 1st floor, stairtower by Room 107;

Interview with the Interim VP Environmental Services on May 21, 2019, at 12:25 PM confirmed the stairtower door frame labels were not legible.


2. Observation on May 21, 2019, between 11:40 AM and 12:38 PM, revealed stairtower door hardware was not labeled fire rated, or the labels were not legible, at the following locations:

a. 11:40 AM, 2nd floor, by the Nurses' Station;
b. 12:38 PM, ground floor, by the Elevator Equipment Room.

Interview with the Interim VP Environmental Services on May 21, 2019, at 12:38 PM confirmed the stairtower door hardware labels were not legible.



 Plan of Correction - To be completed: 07/05/2019

0225

1. The identified doorframe labels listed as a, b, c, & d that failed to be legible have been addressed and now are legible.

2. Stairtower door frames for the remainder of the facility shall be checked by maintenance and corrected, if need be, to ensure labels are legible.

3. Stair tower door frame labels shall be checked quarterly for next two quarters for legible labels.

4. Results to be shared at quarterly QAPI meeting.

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: HCC - Component: 02 - Tag: 0345

Based on document review, observation and interview, it was determined the facility failed to address deficiencies noted on the annual fire alarm report, which serves the entire component.

Findings include:

1. Review of documentation on May 21, 2019, at 9:15 AM revealed the Simplex Fire Alarm Test Report, dated April 2019, indicated five smoke detectors were out of sensitivity range, LED was inoperative in Resident Room 407 & broken housing in the Resident Laundry.

Interview with the Interim VP Environmental Services on May 21, 2019, at 9:15 AM confirmed the deficiencies had not been corrected, at the time of survey.


 Plan of Correction - To be completed: 07/05/2019

0345

1. The deficiencies noted on the Annual Simplex Fire Alarm Test Report listing the five smoke detectors, inoperative LED in Resident Room 407, and broken housing in Resident Laundry
have been fixed, as well as the hanging smoke detectors in Room 310 and 3rd floor by West Elevator.

2. The Maintenance Department shall be educated by the Administrator/designee as to the necessity to efficiently respond to the deficiencies stated in the Annual Simplex Fire Alarm Test Report.

3. Annual Simplex Fire Alarm Test Report shall be shared with the QAPI Committee for review and recommendation.

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: HCC - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler piping system to be free of extraneous weight, on two of four levels within the component.

Findings include:

1. Observation on May 21, 2019 between 11:50 AM and 12:22 PM revealed wires had been placed on the sprinkler piping system, at the following locations:

a. 11:50 AM, 2nd floor, by the elevator and Dining Room entrance;
b. 12:22 PM, 1st floor, by the elevator and stairwell, and the sprinkler pipe hanger was disconnected from the structure above, causing the sprinkler pipe to sag.

Interview with the Interim VP Environmental Services on may 21, 2019 at 12:22 PM confirmed the sprinkler piping system had been subject to extraneous weight.




 Plan of Correction - To be completed: 07/05/2019

0353

1. Wires pressing on the sprinkler piping system have been addressed.

2. The sagging sprinkler pipe has been been re-secured.

3. Maintenance shall inspect the sprinkler piping system at least annually in accordance with NFPA 25 requirements.

4. Maintenance Director/designee shall report on their sprinkler piping inspection to the QAPI Committee.
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: HCC - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed maintain corridor doors to positively latch, and resist the passage of smoke, on two of more than one hundred doors within the component.

Findings include:

1. Observation on May 21, 2019, at 12:04 PM, revealed the door to Room 208 failed to positively latch.

Interview with the Interim VP Environmental Services on May 21, 2019, at 12:04 PM confirmed the corridor door failed to positively latch.

2. Observation on May 21, 2019, at 12:30 PM, revealed the door to Room 109 had a gap between the door frame stop and the door face, greater than one half inch.

Interview with the Interim VP Environmental Services on May 21, 2019, at 12:30 PM confirmed the door could not resist the passage of smoke.



 Plan of Correction - To be completed: 07/05/2019

0363

1. Corridor door to room 208 has been adjusted and now positively latches.

2. The door to room 109 has been adjusted and gap reduced to resist the passage of smoke.

3. All Corridor Doors in the Component shall be checked by maintenance for positive latching and gap widths monthly for the next three months.

4. Results of the Corridor Door Checks shall be reported at the Quarterly QAPI meeting for review and recommendation.


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