Nursing Investigation Results -

Pennsylvania Department of Health
HOLY FAMILY MANOR
Building Inspection Results

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HOLY FAMILY MANOR
Inspection Results For:

There are  36 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.
HOLY FAMILY 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 March 25-26, 2019, at Holy Family 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 01 - Component: 01 - Tag: 0000


Facility ID# 082702
Component 01
Manor Building

Based on a Medicare/Medicaid Recertification Survey completed March 25-26, 2019, it was determined that Holy Family 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 four story, Type II (000), unprotected, noncombustible building, with a partial basement, and unused attic spaces, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting nine of nine smoke compartments.

Findings include:

1. Observation on March 25, 2019, between 10:00 a.m. and 2:30 p.m., revealed the facility exceeds the maximum allowable story height by two stories.

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the facility exceeds the maximum allowable story height for this type of construction .




 Plan of Correction - To be completed: 06/19/2019

Department of Health Life Safety Survey 3/25/2019 3/26/2019 Plan of Correction
Preparation and/or execution of this Provider's Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies as perceived by representatives of the Department of Health Life Safety relative to the on-site survey concluded on March 26, 2019.

The providers Plan of Correction is prepared solely because it conveys this sincere message of the governing body, as follows:

All representative entities of Holy Family Manor have been, are, and will be committed to providing the highest quality of care and services to the elderly, in accordance with, or exceeding all applicable local, state and/or federal laws/mandates regarding the operation of a Long Term Care Facility in Pennsylvania.

Representative entities of Holy Family Manor will evidentially substantiate compliance with all applicable local, state, and/or federal laws/mandates regarding operation of a Long Term Care Facility in the Commonwealth of Pennsylvania during the survey conducted subsequent to that concluded on March 26, 2019.

1. Facility has a five (5) year Time Limited Waiver (TLW) on file until 4/13/2022.
2. Facility requests continuation of the existing F.S.E.S. on file.

NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one location, affecting one of four smoke compartments.

Findings include:

1. Observation on March 25, 2019, at 9:35 a.m., revealed multiple bowed ceiling tiles (non-smoke tight) within the first floor exit access corridor system closest to the boardroom.

Exit interview with the facility administrator and the facility manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the exit access corridor deficiencies.





 Plan of Correction - To be completed: 05/25/2019

1. Maintenance staff will replace bowed ceiling tiles.
2. Maintenance Department will inspect to ensure smoke tight exit access corridors and report findings to QAPI Committee monthly until resolved beginning 4/01/2019.
3. Completion by 5/25/2019.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of nine smoke compartments.

Findings include:

1. Observation on March 25, 2019, between 10:55 a.m. and 11:10 a.m., revealed the following corridor doors lacked smoke-tight integrity:

a. 10:55 a.m., fourth floor staff locker room.
b. 11:10 a.m., third floor resident room 317.

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 04/30/2019

1. Locker Room and Room 317 repaired to ensure smoke tight integrity on 3/25/2019.
2. Re-educate all staff to timely report to maintenance any time a door fails to close and latch properly.
3. Maintenance Department will audit to ensure smoke tight integrity is maintained for all doors and report to QAPI Committee monthly until resolved beginning 4/01/2019.
4. Completion by 4/30/2019.

NFPA 101 STANDARD HVAC: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.
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 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain the heating, ventilation, and air conditioning systems in two instances, affecting nine of nine smoke compartments.

Findings include:

1. Observation between 10:12 a.m. on March 25, 2019, and 9:30 a.m. on March 26, 2019, revealed the following:

a. On March 25, 2019, at 10:12 a.m., the elevator shaft enclosure exhaust air is ducted into the attic spaces.
b. On March 26, 2019, at 9:30 a.m., the facility lacked required four year, fire damper preventative maintenance documentation.

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the HVAC deficiencies.




 Plan of Correction - To be completed: 05/25/2019

1. The Opening in the elevator shaft used to vent the accumulation of gases will be vented to the outside as per ASME 17.1 2010 edition. Holy Family Manor is in process of coordinating this work to be completed by an outside vender.
2. Holy Family Manor signed a contract with outside vender, Brand Services LLC Company on 3/28/2019 to complete the fire and smoke damper inspection. Inspection scheduled for 4/10/2019.
3. Holy Family Manor will continue to utilize contracted vender for each 4 year fire damper preventative maintenance inspection.
4. Complete by 5/25/2019.

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


Facility ID# 082702
Component 02
McShea Building

Based on a Medicare/Medicaid Recertification Survey completed March 25-26, 2019, it was determined that Holy Family 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 (000), unprotected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain means of egress in one location, affecting one of four smoke compartments.

Findings include:

1. Observation on March 26, 2019, at 8:22 a.m., revealed multiple storage items were located within the second floor, McShea "bridge."

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the means of egress deficiency.



 Plan of Correction - To be completed: 04/30/2019

1. All items to be relocated to proper storage areas.
2. Re-educate all staff on proper storage areas and need to ensure accessible means of egress.
3. Maintenance Department will audit to ensure accessible means of egress in corridor is maintained and report to QAPI Committee monthly until resolved beginning 4/ 01/2019.
4. Completion by 4/30/2019.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0311

Based on observation and interview, it was determined the facility failed to construct and maintain vertical openings, affecting nine of nine smoke compartments.

Findings include:

1. Observation on March 25, 2019, between 10:00 a.m. and 2:30 p.m., revealed vertical openings throughout this component lacked required one, and two hour fire resistive integrity. These enclosures consist of the following:
a. HVAC shafts, soiled linen chutes, trash chutes, and stair tower enclosures.

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the vertical opening deficiencies.



 Plan of Correction - To be completed: 05/30/2019

1. Holy Family Manor is working with vendors to provide plans to spray fire proofing on structural members to acheive a 2 hour fire resistive integrity of the smoke compartment.
2. In accordance with the TLW already in place, the attic space would become an interstitial space of the 3rd floor and bring the building back to construction type II (222).
3. No mechanical shaft is open to the attic space as there is a floor present inside of each chase area. All mechanicals are sealed and ducts have fire dampers and angles. The top of the ceilings of the stair towers need to be completed in order to provide a complete 2 hour enclosure. The unprotected steel that sits in the elevator 2 hour barrier needs to be sprayed with fire proofing so as to provide a complete 2 hour fire rating of that component within the assembly.
4. Holy Family Manor will bring these plans to Department of Health Plan Review prior to initiation of work.
5. Facility requests continuation of the existing F.S.E.S. on file.

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: BUILDING 02 - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of four smoke compartments.

Findings include:

1. Observation on March 26, 2019, at 8:02 a.m., revealed storage items were located within the elevator machine room.

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the hazardous area enclosure.



 Plan of Correction - To be completed: 04/30/2019

1. Maintenance staff removed all unauthorized items from elevator machine room to proper storage areas by 4/3/2019.
2. Re-educated all maintenance staff on proper storage areas.
3. Maintenance Director will audit to ensure compliance is maintained and report to QAPI Committee monthly until resolved beginning 4/ 01/2019.
4. Completion by 4/30/2019.

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: BUILDING 02 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of four smoke compartments.

Findings include:

1. Observation on March 25, 2019, between 8:33 a.m. and 8:45 a.m., revealed the following doors were held open by unapproved means:

a. 8:33 a.m., resident room 46.
b. 8:45 a.m., pantry.

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 04/30/2019

1. Obstructions to doors to room 46 and the pantry were removed and corrected on 3/27/2019.
2. Re-educate all staff that doors may not be held open by unapproved means.
3. Maintenance Department will audit to ensure compliance is maintained for all doors and report to QAPI Committee monthly until resolved beginning 4/01/2019.
4. Completion by 4/30/2019.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation walls in two locations, affecting two of four smoke compartments.

Findings include:

1. Observation on March 25, 2019, between 8:44 a.m. and 9:12 a.m., revealed the following:

a. 8:44 a.m., a penetration of the smoke barrier separation wall within the east soiled linen room.
b. 9:12 a.m., a non-rated, wall access panel within the east wing smoke barrier separation wall (storage room).

Exit interview with the facility administrator and the facilities manager on March 26, 2019, between 10:30 a.m. and 10:45 a.m., confirmed the smoke barrier separation wall deficiencies.



 Plan of Correction - To be completed: 04/30/2019

1. Penetration in soiled linen room was filled with fire caulk on 4/3/2019.
2. Non-Fire rated access panel was replaced with an approved fire rated access panel on 4/3/2019.
3. Maintenance Department will audit to maintain smoke barrier separation walls are maintained throughout facility and report to QAPI Committee monthly until resolved beginning 4/01/2019.
4. Completion by 4/30/2019.


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