Nursing Investigation Results -

Pennsylvania Department of Health
EPHRATA MANOR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EPHRATA MANOR
Inspection Results For:

There are  32 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.
EPHRATA MANOR - 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 30, 2019, at Ephrata Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID #053502
Component 01
Main Building (Long Term Care and Core Building)

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2019, it was determined that Ephrata Manor 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 two-story, Type II (111), protected noncombustible structure, with a basement, which 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 - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be in good repair, and within the allowed gap margin, at one of three floors within the component.

Findings include:

1. Observation on January 30, 2019, at 3:05 PM revealed the common wall doors separating the Nursing Care Core Hall to the Apartments, in the basement, were repaired with wood filler.

Interview with the Director of Maintenance on January 30, 2019, at 3:05 PM confirmed the doors were repaired with an unapproved substance.


2. Observation on January 30, 2019, at 3:18 PM revealed the common wall door separating the Nursing Care to the Apartments, by Laundry, in the basement, had a gap, greater than 1/4 inch, at the top hinge side.

Interview with the Director of Maintenance on January 30, 2019, at 3:18 PM confirmed the doors exceeded the allowed gap margin.


3. Observation on January 30, 2019, at 3:25 PM revealed the common wall door separating the Core to the Personal Care, in the basement, had a gap, greater than 1/4 inch at the top hinge side, and had holes in the frame from old hardware.

Interview with the Director of Maintenance on January 30, 2019, at 3:25 PM confirmed the doors exceeded the allowed gap margin, and had penetrations.




 Plan of Correction - To be completed: 03/22/2019

In order to maintain compliance with allowed gap margin. The door located separating Nursing Care Core Hall to the apartments will be replaced. Door will be ordered on 2/18/2019.

Time Limited Waiver requested due to length of time to receive and install the door. This will be completed May 13 2019.

The door referenced in #3 separating the Core to Personal care will be repaired upon receiving the parts. The door is expected to be repaired by March 22, 2019.

All deficiencies will be reported to and monitored by Director of Environmental Services and reported to QA Committee on a quarterly basis to ensure compliance.
NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain rated floor/ceiling assembly, affecting two of three floors within the component.

Findings include:

1. Observation on January 30, 2019, at 3:20 PM revealed a 4" and a 3" PVC pipe penetrating the ceiling/floor assembly, in the basement Central Supply, which lacked fire collars.

Interview with the Director of Maintenance on January 30, 2019, at 3:20 PM confirmed there were penetrations.


 Plan of Correction - To be completed: 02/07/2019

Fire stop collar added to PVC drain pipe in Central Supply. This was completed on 2/7/2019.
All deficiencies will be reported to and monitored by Director of Environmental Services/designee and reported to QA Committee on a quarterly basis to ensure compliance.

Date of completion 2/7/2019.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on three of three floors within the component.

Findings include:

1. Observation on January 30, 2019, between 1:30 PM and 3:17 PM revealed the following rated door deficiencies:

a. 1:30 PM, 2nd floor, Center Stairtower door;
b. 1:40 PM, 2nd floor, South Stairtower door had a gap on the top and strike side;
c. 1:50 PM, 2nd floor, North Stairtower door had a gap on the top and strike side;
d. 2:10 PM, 1st floor, West Stairtower door had a gap on the top and strike side;
e. 2:15 PM, 1st floor, South Stairtower door had a gap on the top;
f. 3:00 PM, basement, Nursing Stairtower, had a gap on the top hinge side;
g. 3:17 PM, basement, Core/Apartment Stairtower had a gap on the top and hinge side.

Interview with the Director of Maintenance on January 30, 2019, at 3:17 PM confirmed the stairtower doors exceeded the allowed gap margins.




 Plan of Correction - To be completed: 02/18/2019

In order to maintain compliance of stair tower doors with allowed gap margin. Replacement doors will be ordered on 2/18/2019.

A time limited waiver is requested due to the length of time to order and install doors.

Deficiencies will be reported to and monitored by Director of Environmental Services and reported to QA Committee on a quarterly basis to ensure compliance.

Completion of this project would be set for May 13, 2019.

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to positively latch, on one of three floors within the component.

Findings include:

1. Observation on January 30, 2019, at 3:28 PM revealed the door to the basement Trash Room would not positively latch.

Interview with the Director of Maintenance on January 30, 2019, at 3:28 PM confirmed the door failed to positively latch.



 Plan of Correction - To be completed: 03/06/2019

Repair of Trash Room Door will take place on March 6, 2019 when parts arrive.

All deficiencies will be reported to and monitored by Director of Environmental Services/Designee and reported to QA committee on a quarterly basis to ensure compliance.

Completion Date: 3/6/2019
NFPA 101 STANDARD Corridor - 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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, on two of three floors within the component.

Findings include:

1. Observation on January 30, 2019, between 1:45 PM and 2:30 PM, revealed the following corridor door failed to positively latch:

a. 1:45 PM, Quiet Room;
b. 1:47 PM, Resident Room 202;
c. 2:30 PM, Resident Room 129.

Interview with the Director of Maintenance on January 30, 2019, at 2:30 PM confirmed the corridor doors failed to positively latch.


 Plan of Correction - To be completed: 02/11/2019

Latch adjustment made to Quiet Room, Resident Room 202, and Resident Room 129 on 2/11/2019.

All deficiencies will be reported and monitored by Director Environmental Services/Designee. All audits will be reported to QA committee on a quarterly basis to ensure compliance.

Date of Completion: February 11, 2019.

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